Amphetamine Use Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services equivalent to ASAM 3.1. For Dimension 1, The patient’s urine toxicology screening on admission was positive for amphetamine, fentanyl, methamphetamine, and tetrahydrocannabinol (THC). The patient was placed on medications for detoxification, including a lorazepam taper, clonidine, gabapentin, Suboxone, and promethazine. The patient is experiencing or anticipated to imminently experience moderately severe to severe signs and/or symptoms of intoxication that otherwise meet Intoxication and Associated Risks Criteria for treatment at Level 2.7 and the patient requires after-hours medical management and/or nursing care.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focus on six dimensions to determine the appropriate level of care, which includes: (1)intoxication and withdrawal potential; (2)biomedical conditions; (3)emotional, behavioral, and cognitive conditions; (4)readiness to change; (5)relapse, continued use, or continued problem potential; and (6)recovery environment. Based on ASAM criteria, this patient meets the requirements for ASAM 3.1 RTC services. For dimension 1, the patient was not intoxicated upon admission.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential substance abuse treatment he received. Findings: The physician reviewer found that, to objectively determine if the patient met the criteria for residential substance abuse treatment, the Level of Care Utilization System (LOCUS) guidelines are applicable. This is an accepted, national standard for determining the appropriate level of care for adults. On the date of service in question, the patient demonstrated a low risk of harm (score 2) as there was no documentation of prior suicide attempts and the patient did not have any suicidal ideation on that date.

The patient is a 23-year-old female with approximately a two-year history of bulimia nervosa with episodes of binging and purging up to three times per day. Each binge lasted one to two hours with the patient sometimes eating to the point of physical pain. The patient also noted having grown increasingly depressed in the seven months prior to admission following the breakup of a relationship with her boyfriend, with subsequent lethargy, increasing social isolation, and irritability. This was compounded by her use of amphetamine, particularly flagrant in the three to four months prior to her inpatient admission in October 2002.

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 amphetamine use disorder, then check the rights and deadlines that apply to your plan.