Depressive Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for a minimum of 30 additional days. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.

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 meets 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. For dimension 1, the patient underwent withdrawal management for benzodiazepine withdrawal earlier in his treatment stay.

Where the denial was upheld

Findings: The physician reviewer found that The patient has requested reimbursement for residential treatment center (RTC) services (ASAM level 3.5). Per 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. For dimension 1, the patient did not have symptoms of acute withdrawal after detoxification but did report post-acute withdrawal symptoms (PAWS) such as fatigue and aching muscle and joints. The patient’s withdrawal needs were safely managed in a Level 3.5 setting.

The patient is a 66-year-old female who was diagnosed with depressive disorder, possible somatization disorder, chronic fatigue syndrome, interstitial cystitis, and irritable bowel syndrome. She has been treated in outpatient therapy for 10 years by a lay therapist and via medications from a psychiatrist for the past two years. The patient has had varying dosages of Celexa, Klonopin, and trazodone from her psychiatrist with varying degrees of success in lessening her anxiety and depression. The patient has requested coverage for continued outpatient therapy sessions. Records submitted by the patient’s psychiatrist reveal the following: 12/25/02: Affect brighter. Depression decreased. Going out more. Drove a few times. Involved in meal preparation. Walking without walker or wheelchair. Sleep good. Appetite increased.

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 depressive disorder, then check the rights and deadlines that apply to your plan.