Polysubstance Dependence denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is an 18-year-old female admitted to residential treatment in March 2006 with an increased level of depression and escalating substance abuse. The record indicates she begun to use alcohol at the age of 12 and progressed to daily use between the ages 14 to 16. The patient later used cannabis and began using amphetamine at age 13, initially snorting, then smoking, and finally mixing it with heroin and injecting it in the year prior to admission. She reported daily use of significant quantities of amphetamine and heroine. The patient described herself as “always depressed” and noted seasonal variation in her mood, typically more depressed in the winter months. Her symptoms included irritability, disrupted sleep patterns, low energy, and low self-esteem. The patient often expressed hopelessness and suicidal ideation and claimed to have made several suicide attempts previously.

The patient is a 17-year-old male with a history of ADHD, polysubstance dependence, oppositional defiant disorder, and narcissistic traits. He was admitted to residential treatment in September 2004. He had been substance dependent for the past five years, involved primarily with marijuana and alcohol. Admission was considered necessary due to the patient’s persistent aggressive behavior at home. The behavior involved physical aggression in the past, but immediately prior to his admission it consisted of verbal abuse and violation of household rules. The patient is also noted to have felt depressed for years. Overall, the patient’s perception of his behavior was “Do drugs, hit them, and don’t listen.” Family dynamics included an overly permissive mother who rationalized the patient’s behavior and a fundamentally uninvolved father.

Where the denial was upheld

The patient is a 15-year-old female who was admitted to an inpatient psychiatric facility on 9/28/04 for treatment of continued running away from home, polysubstance use involving marijuana, amphetamine and cocaine use, promiscuous sex, stealing money, and continued defiance at home. The patient’s psychiatrist noted the patient had a long history of being very oppositional. She was also noted to refuse to take responsibility for her behavior and the patient cited feeling hopeless and worthless as secondary to being adopted. She was initially diagnosed as having a mood disorder – not otherwise specified and oppositional defiant disorder. She was seen in a variety of group therapies and had family therapy with her adopted mother and father via the telephone, but not in person.

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment level of care services for treatment of the enrollee’s depressive disorder and polysubstance dependence. The physician reviewer found that although episodic treatment is often necessary for patients afflicted with psychotic illness and substance use disorders, the services provided were not medically necessary for treatment of this patient’s medical condition. There was no psychiatric evaluation, psychosocial assessment, history and physical, treatment plan or integrated summary justifying the necessity of the placement. The progress notes that were provided did not describe behaviors, symptoms, or treatment interventions that require a 24-hour medically-supervised setting. The patient was anxious.

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