Insomnia denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 likelihood of engaging in risky substance use diso…

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services, and authorization and coverage for trazodone. The Health Plan has denied this request indicating that the services and medication at issue were not and are not medically necessary for treatment of the enrollee’s behavioral health issues. The records provided for review support the medical necessity of the RTC services, and treatment with trazodone, for management of this patient’s behavioral health issues.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has a history of chronic pain, sickle cell disease and insomnia. The medical records indicate she takes multiple medications including Norco, an opiate pain medication. The provider noted the patient has had an increase in pain crisis in the last several years with the most recent on 1/30/22. There was no indication of any current complications. The patient was being treated for depression and the plan of care included a follow-up with the psychiatry department. There was no indication that the patient was having sleep disturbance. In an addendum, the patient was noted to need something for sleep. Venlafaxine was noted to be ineffective. In August the patient presented with acute abdominal and back pain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ambien 25mg.At issue in this case is whether the Ambien is medically necessary to treat the patient’s medical condition as defined in Health and Safety code section 1374(a)(3)(A) set forth below. “Medically necessary treatment of a mental health or substance use disorder” means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration.

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