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Cocaine Use Disorder: when insurers say no, reviewers often say yes
In 24 published external-review decisions involving cocaine use disorder, independent physician reviewers overturned the insurer’s denial 58.3% of the time.
Published decisions
24
2001–2026
Overturned
58.3%
14 denials reversed
Most-fought treatments for cocaine use disorder
What insurers denied — and how those fights ended.
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment Center | 17 | 58.8% |
Typical time to a decision
21 days
Most land between 5 and 21 days
Handled as urgent
33.3%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
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
Worth reading too — these show what an appeal has to overcome.
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 outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
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 use disorder was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.