Cannabis Dependence: 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) services. The 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 composite score is then used to determine the level of care needed.

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 17-year-old male with an approximate four-year history of predominantly marijuana use, but supplemental use of other drugs such as cocaine. He was admitted to residential treatment in March 2005 following a six-week wilderness program. This had followed having been enrolled in another residential treatment program for six months, though taken out prematurely. Thereafter, he relapsed in his use of drugs, hence his referral to the wilderness program. The patient was referred to the residential program due to his mother’s concern that he might relapse yet again. The patient identified his drug use mostly as stemming from his upset over his parents’ divorce when he was 12, since which time he had used drugs to numb his various feelings. He also noted frequently feeling depressed.

The patient is a 19-year-old female with a history of long-standing use of marijuana. She was dismissed from college due to recurrent use of the substance as well as poor academic performance. The patient had been using marijuana 3-4 times per week with last use a week prior to entrance to residential treatment. She was eventually arrested on possession charges and informed in court that charges would be dismissed if she completed a residential treatment program. The patient also previously used Xanax to lessen her anxiety with last use a month prior to entering residential treatment. After entering residential treatment the patient was diagnosed with cannabis dependence, alcohol abuse, anxiety disorder – not otherwise specified, attention deficit disorder, depressive disorder – not otherwise specified, and borderline traits.

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