Opioid Dependence denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services provided. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s opioid dependence, Bipolar II Disorder, and attention deficit hyperactivity disorder.At issue in this case is whether the requested residential treatment center services provided are medically necessary for treatment of the enrollee’s medical condition.The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment, or similar care higher than outpatient, is indicated for patients who “do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use…lack sufficient social and vocati…

The patient is a 55-year-old woman who has a long history of chronic pain treated with analgesics. She has been tried on a multitude of opiate analgesics, anti-anxiety medications, and antidepressants without much relief. The patient has experienced increased tolerance of opiates as well as psychological dependence on the drugs. She has multiple physical problems, namely, fibromyalgia, hypertension, arthritis, hypothyroidism, colitis, chronic abdomen pain, and a history of abnormal heartbeat, chronic anemia, and hepatitis A. She also takes multiple medications. She lives with her husband and children; they are managing her medications, which is helping the situation somewhat.

Where the denial was upheld

The patient is a 46-year-old female with long-standing opioid dependence, sedative-hypnotic abuse, and alcohol dependence in remission, generalized anxiety disorder, and depression NOS vs. major depression. She was admitted to an intensive outpatient program through her Health Plan on 4/5/04. She continued in this program until approximately 5/26/04, having become largely abstinent of substance abuse during this time. She was later admitted to inpatient care for detoxification on 6/7/04, after having taken 36 Morphine pills on 6/3/04, noting a prior overdose six weeks prior wherein she was hospitalized for five days. She was subsequently detoxified with Suboxone, tolerating the downward taper as well, last dose administered on 6/21/04. After this time, she was transitioned to seeing a psychiatrist, who she saw from 6/22/04 to 12/3/04.

Nature of Statutory Criteria/Case Summary: The patient has a history of opioid dependence, alcohol dependence, cannabis dependence, cocaine dependence, autistic disorder and borderline personality disorder. The patient was admitted to a residential treatment center (RTC) on 8/13/18. The patient was trying to stop heroin without medical assistance, with fear of relapse. The records document that the patient had passive suicidal thoughts, but denied homicidal thoughts, and did not exhibit any psychosis. At the time of admission, the patient was living with their partner. The records report that the patient has a history of four suicide attempts in the past. At issue is whether the residential treatment services that received from 9/10/18 to 10/1/18 were medically necessary to treat this patient’s medical condition.

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