ETOH Abuse Addict: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for residential mental health and substance use treatment for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the patient was diagnosed with alcohol use disorder severe. She presented for detoxification in withdrawals with a clinical institute withdrawal assessment (CIWA) for alcohol of 21. Due to her CIWA score, she was placed on a Valium taper. The patient reported that she drank four bottles of wine a day and has a history of drinking liquor, nail polish remover, and vodka with wine. She binge drinks every three to four months then she would get sober and attend meetings and groups for up to 50 days, then she relapses. She was drinking daily for the month prior to admission.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee’s behavioral health condition.Findings: Inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness. However, there is no precise, standard algorithm to determine the optimal level of care and length of stay. The standard of care is to perform an initial and serial systematic evaluations to determine the least restrictive environment and appropriate duration of treatment.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential substance abuse treatment for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found the patient presented to the residential treatment center with a history of alcohol use disorder. He expressed motivation for his treatment and presented on a voluntary basis. During treatment, he was noted to be cooperative and calm, and breathalyzer evaluations indicated that he did not relapse during treatment. He was also noted to show insight into his illness. The progress notes did not document psychosis, paranoia or mania symptoms during the residential treatment stay. He had depression and anxiety that were both noted to be mild. The records did not indicate severe symptoms that would require intensive psychiatric care.

The patient is a 19-year-old female with a history of long-standing use of marijuana. She was dismissed from college due to recurrent use of the substance as well as poor academic performance. The patient had been using marijuana 3-4 times per week with last use a week prior to entrance to residential treatment. She was eventually arrested on possession charges and informed in court that charges would be dismissed if she completed a residential treatment program. The patient also previously used Xanax to lessen her anxiety with last use a month prior to entering residential treatment. After entering residential treatment the patient was diagnosed with cannabis dependence, alcohol abuse, anxiety disorder – not otherwise specified, attention deficit disorder, depressive disorder – not otherwise specified, and borderline traits.

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 etoh abuse addict was denied, the published record says the denial is worth fighting.