Polysubstance Abuse denials in California external review
In the California DMHC record, independent physician reviewers decided 59 published external-review cases involving polysubstance abuseand overturned the plan’s denial in 35.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for polysubstance abuse
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment | 18 | 55.6% |
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’s parent has requested reimbursement for partial hospitalization program (PHP) services with ROWI Teen and Parent Wellness Center. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association for Community Psychiatry (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 is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns.
Where the denial was upheld
The patient is a 24-year-old female with long-standing bulimia nervosa, polysubstance abuse, and major depression, previously treated in a number of eating disorder programs. She was admitted to residential treatment on 1/11/05 due to binging and purging cycles lasting all day within the past two years. This was interspersed with excessive sleeping, drinking alcohol 2-3 nights a week to the point of intoxication, promiscuity and use of methamphetamine as well as cocaine almost daily. Apparently, the patient found the drug use useful in partially helping her stop the binging. She had been unable to hold a job due to lateness, fatigue, and sense of illness due to the vomiting.Review of her chart notes indicates the patient did become variably involved in her residential treatment program, consisting of various group therapies, inclusive of family therapy, and pharmacotherapy.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement and prospective authorization and coverage for the intensive outpatient program (IOP) services for treatment of the enrollee’s polysubstance abuse. Findings: The physician reviewer found the progress notes do not reflect severe emotional outbursts or other issues that would warrant any intensive type of treatment. The progress notes indicate the patient was cooperative in treatment. His family was engaged in treatment and it appears that they were experiencing an amicable relationship. The progress notes do not reflect arguments or outburst during family therapy sessions. The progress notes do not indicate that the patient had any serious mood symptoms or psychosis. The progress notes indicate the patient was not receiving any type of substance abuse treatment prior to his enrollment in the IOP.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 polysubstance abuse, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY