Alcohol Abuse: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment. The submitted documentation supports the medical necessity of a portion of the services at issue. This patient was struggling with identity formation. The patient had poor self-esteem and self-defeating coping strategies in context of anxiety, depression, alcohol abuse and poor motivation. As such, a conservative treatment course was to be expected. On 2/07/18, there was no discharge plan in place. The patient felt self-hatred and was engaged in all-or-none thinking while struggling with urges to drink alcohol. On 2/09/18, the patient had visions of drinking and starving upon discharge. The patient needed staff support during lunch.

Where the denial was upheld

The patient is a 17-year-old male previously diagnosed with oppositional defiant disorder, dysthymic disorder, alcohol abuse, cannabis abuse, and parent-child relational problems, admitted to residential treatment in May 2005 at his parents request due to his behavior at home, replete with anger, defiance, dwindling academic performance, and poor choices in peer relationships. He was also smoking marijuana and drinking alcohol, perceiving neither as a problem. The patient’s perspective was that he was “hanging out with the wrong crowd, drinking alcohol, and smoking pot.” His parents were concerned that he was going to get in trouble with the law or get hurt in a fight. Parenthetically, the patient was without any prior history of infractions of the law or arrests and had no history of physical fighting.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment center level of care services for treatment of the enrollee’s alcohol abuse. Findings: The physician reviewer found that the patient’s withdrawal symptoms were mild-to-moderate in nature, and cravings were moderate. She was not a danger to herself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms to warrant residential level of care. Her activities of daily living were intact. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with her care. She was medically and psychiatrically stable to the point that she could have been managed at an ambulatory level of care.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for alcohol abuse was denied, the published record says the denial is worth fighting.