Alcohol Dependence denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 50-year-old male with a 35-year history of alcohol abuse. Prior to his admission to substance abuse treatment the patient was drinking on the order of two to three bottles of wine per sitting, typically drinking three to four times per week, in addition to periodic use of marijuana. The latter involved one joint per day, last on 6/1/04, and the submitted notes indicate the patient last drank two bottles of wine, two beers, and three cocktails on 6/22/04 prior to entering residential treatment on 6/25/04. The patient noted a very fractious relationship with his wife; a divorce was soon to be finalized due to his extramarital affairs. In addition, the patient had a history of yelling at his wife and their two children quite a bit and pushed his wife on occasion.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services.The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had significant risk of harm due to a significant history of destructive acts in the home including aggression towards parents and property destruction. Given the patient’s history of ADHD issues with poor impulse control, substance use, and also pre-morbid anxiety concerns, the patient’s risk of harm was significant. The patient appeared to require extra support for skills development to assist in managing low frustration tolerance, irritability, anger, and drug cravings.

Where the denial was upheld

The patient is a 37-year-old-female who was admitted for inpatient detoxification in November 2005. Her provider indicated she “sometimes” had suicidal ideation, although there was no plan or specific intent. In November 2005 the progress note indicates the patient was “doing well” by self report. No symptoms of withdrawal were documented; she was felt to be “stable” and her vital signs were normal. The patient transferred to residential care in November 2005 and her diagnoses were documented as alcohol and cocaine dependence.In December 2005 there was a “revised” Medical Physician’s Order Sheet noting diagnoses of bulimia nervosa, ADHD, depression, alcohol dependence and cocaine dependence. The patient’s medications were changed from Celexa to Prozac and Topamax, weights were ordered three times per week and there were instructions to encourage five meals per day.

The patient is a 53-year-old male who was admitted to residential treatment in October 2005, ostensibly for treatment of alcohol abuse. Admission diagnoses included alcohol dependence, major depression, post-traumatic stress disorder (PTSD), and myofacial pain. The patient had been involved in an airplane incident in which he sustained injuries following extreme turbulence while flying to Brazil in 1993 on a work assignment, resulting in a number of injuries to his jaw, back, and knees. Subsequently, and following a number of restorative surgeries to his jaw, he experienced very severe pain in his back and legs as well as severe headaches. In part, this led to his discontinuing work, thereafter reliant on his wife.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving alcohol dependence, then check the rights and deadlines that apply to your plan.