Cannabis Use Disorder: 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 authorization and coverage for residential treatment center (RTC) services (for no less than 45 days). For dimension 1, the patient has been at significant risk of harm (score 3) due to a history of self-harm and suicidal ideation. The patient has not reportedly attempted suicide. She denies current suicidal or homicidal ideation. The patient has been running away from home and using cannabis and nicotine daily. There is an indication or report of incidents of acting without thinking, self-mutilation, and running away. In addition, the records support no active suicidal or homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior. For dimension 2, the patient has demonstrated serious functional impairment (score 4).

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 Psychiatry studies have unified and created a single instrument, to determine the intensity of services needed. The 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. For dimension 1, the patient did not have any symptoms of acute withdrawal after completing detoxification services and was being treated in level 3.1 RTC. Given these findings, the patient meets 3.1 requirements for this dimension.

Where the denial was upheld

Nature of Statutory Criteria: The patient has requested reimbursement for RTC services (ASAM 3.5).For Dimension 1 The patient was not intoxicated upon admission and his urine toxicology was positive for cannabis. The patient was placed on medications for detoxification including phenobarbital, Lorazepam, Zofran as needed for nausea, and Seroquel as needed for sleep. The patient had last used alcohol six days prior to admission, cannabis 10 days prior to admission, and benzodiazepines seven days prior to admission. Overall, the patient was experiencing or anticipated to imminently experience mild to moderate signs and/or symptoms of intoxication that could have been addressed in any level of care as needed and thus did not require a medically managed addiction treatment program for intoxication management. Given these findings, the patient meets ASAM 3.5 requirements for this dimension.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) (ASAM 3.5) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC services for the time period under review. The ASAM criteria focus 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 likelihood of engaging…

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