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

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for intensive outpatient program (IOP) level of care services. Findings: The physician reviewer found that American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement.

The patient is a 17-year-old male referred for residential treatment due to increasingly aggressive behavior at school. Other behaviors included extensive use of marijuana and alcohol beginning at age 11, threatening to make bombs, threatening to shoot people, thievery, and sexual deviance. The latter consisted of bestiality, manipulation of peers to engage in sexual acts and sexual intimidation towards his sister. There is a 2001 report, which cites direct sexual abuse by his older brother on at least four to five occasions, as well as the observation of the brother forcing his sister to engage in sexual acts.

Where the denial was upheld

The parent of a 16-year-old male enrollee has requested resumption of intensive outpatient program treatment for the enrollee’s cannabis abuse, major depressive disorder, recurrent episode, and history of attention deficit disorder. Findings: The physician reviewer found that the submitted documentation fails to demonstrate that treatment at the intensive outpatient program level of care is medically necessary. The patient completed intensive outpatient programming, and he had an aftercare plan in place. There was no mention in the medical record of clinical deterioration or failure to meet treatment goals that would warrant an extension of intensive outpatient program services. Additionally, the best evidence for treatment of cannabis dependence is motivational interviewing or cognitive behavioral therapy in the outpatient setting.

A 41-year-old male enrollee has requested intensive outpatient program (IOP) level of care services for treatment of his alcohol dependence and cannabis abuse. Findings: The physician reviewer found that the records provided for review indicate this patient demonstrated progress in IOP treatment. Specifically, he attended and actively participated in groups, he was involved in Alcoholics Anonymous (AA) and had secured a sponsor. Urine toxicology screenings were negative for illicit substances. In addition, he does not show any impairment in functioning, and there are no comorbid medical or psychiatric conditions. He shows good self care and impulse control. He has remained sober since the said date. He has expressed motivation to change and is a willing participant in this process. While there is the potential for relapse, he has an understanding of issues surrounding relapse.

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 cannabis abuse was denied, the published record says the denial is worth fighting.