Cocaine Dependence: when insurers say no, reviewers often say yes

Where the denial was overturned

A 52-year-old male requested reimbursement coverage for residential treatment services provided from a specific date and forward for treatment of his cocaine dependence and major depression. Findings: The physician reviewer found that modern psychiatric practice is aimed at treating individuals in the least restrictive setting to consolidate treatment gains and foster autonomy, resilience, and mental wellness. Due to multiple factors and unique considerations, determination of the appropriate level of care for patients with substance dependence is a challenging endeavor. Clinical guidelines and patient placement criteria have been developed to assist with the determination process. In this patient’s case, his substance abuse dominated social and family dynamics. Further, he currently lacks a harmonious living environment and social supports to facilitate recovery.

A 25-year-old male enrollee requested substance abuse residential for treatment of his alcohol, marijuana and cocaine dependence. Findings: A 25-year-old male enrollee requested substance abuse residential for treatment of his alcohol, marijuana and cocaine dependence. Findings: The physician reviewer found that substance abuse residential rehabilitation was medically indicated for the treatment of this patient. Based upon the medical records, the services provided were for active treatment and were reasonably expected to improve the patient’s condition while preventing a more serious episode of illness. Further, the duration of treatment was consistent with community treatment standards. All told, substance abuse residential rehabilitation was medically indicated for the treatment of this patient.

Where the denial was upheld

The patient is a 37-year-old-female who was admitted for inpatient detoxification in November 2005. Her provider indicated she “sometimes” had suicidal ideation, although there was no plan or specific intent. In November 2005 the progress note indicates the patient was “doing well” by self report. No symptoms of withdrawal were documented; she was felt to be “stable” and her vital signs were normal. The patient transferred to residential care in November 2005 and her diagnoses were documented as alcohol and cocaine dependence.In December 2005 there was a “revised” Medical Physician’s Order Sheet noting diagnoses of bulimia nervosa, ADHD, depression, alcohol dependence and cocaine dependence. The patient’s medications were changed from Celexa to Prozac and Topamax, weights were ordered three times per week and there were instructions to encourage five meals per day.

The patient is a 46-year-old male with a history of substance abuse and depression. In June 2005 the patient was admitted to a partial hospitalization program. A patient assessment completed on admission indicated that his mother and father were supportive; that he had a marked weight loss; that he was binging on cocaine on a daily basis (up to $200-300/day); that he was isolating himself; that he was motivated for treatment; that he was sad, irritable and angry, and that he was “just getting settled” into a Sober Living house with several other men. The submitted chart notes reflect the following. A psychiatric evaluation performed in June 2005 noted a prior history of major depressive disorder characterized by depressed mood, anhedonia, insomnia, suicidal ideation and hopelessness even when sober.

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