Cocaine Use Disorder denials in California external review
In the California DMHC record, independent physician reviewers decided 24 published external-review cases involving cocaine use disorderand overturned the plan’s denial in 58.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for cocaine use disorder
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment Center | 17 | 58.8% |
What the reviewers wrote
Where the denial was overturned
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).Findings: The physician reviewer found that For dimension 2, the patient’s biomedical conditions, including physical health concerns and pregnancy-related concerns, should be discussed and scored. In this case, the patient has had no acute medical problems during her RTC stay that have interfered with her treatment. She was prescribed Theraflu for an upper respiratory infection. The patient was sleeping poorly at night and was prescribed Geodon for bipolar disorder, which was causing her insomnia. Overall, the patient has had no specific treatment needs related to physical health concerns.
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…
Where the denial was upheld
Findings: The physician reviewer found that 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. Applying the ASAM 3.5 criteria, this patient did not meet the requirements for RTC level of care services. For dimension 1, the patient had no symptoms of withdrawal and no history of serious withdrawal symptoms.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for RTC services from 7/28/22 forward. The 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 no longer had withdrawal symptoms per the records. The patient’s withdrawal needs can be safely managed in a Level 3.5 setting.
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 cocaine 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