Benzodiazepine Use Disorder denials in California external review
In the California DMHC record, independent physician reviewers decided 23 published external-review cases involving benzodiazepine use disorderand overturned the plan’s denial in 82.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for benzodiazepine use disorder
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment Center | 22 | 81.8% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A 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 for the time period under review. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and associated risk, withdrawal and associated risks, and addiction medication needs; (2) biomedical conditions including physical health concerns and pregnancy-related concerns; (3) psychiatric and cognitive conditions and history including active psychiatric symptoms and persistent disability; (4) substance use-related risks including the likelihood of engaging in risky substance use and the likel…
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). For Dimension 1 The patient’s urine toxicology on admission was positive for amphetamine, benzodiazepine, methamphetamine, and THC. The patient’s medications include a lorazepam taper for detoxification, clonidine as needed for detoxification and blood pressure, and promethazine as needed for nausea. Upon admission, the patient had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 4 and a clinical opiate withdrawal scale (COWS) score of 6. He reported cravings.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC services. ASAM criteria focuses 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.For dimension 1, the patient did not have any symptoms of withdrawal. Given these findings, the patient met ASAM 3.5 requirements for this dimension.For dimension 2, the patient presented to RTC with a lack of acute medical problems.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services. Several Psychiatric studies have unified and created a single instrument to determine the intensity of services needed. Per the study criteria, this patient did not meet Level 3.5 criteria for RTC services for the time period under review. The criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and associated risk, withdrawal and associated risks, and addiction medication needs; (2) biomedical conditions including physical health concerns and pregnancy-related concerns; (3) psychiatric and cognitive conditions and history including active psychiatric symptoms and persistent disability; (4) substance use-related risks including the likelihood o…
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 benzodiazepine use disorder, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY