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Polysubstance Use Disorder: when insurers say no, reviewers often say yes
In 23 published external-review decisions involving polysubstance use disorder, independent physician reviewers overturned the insurer’s denial 82.6% of the time.
Published decisions
23
2001–2026
Overturned
82.6%
19 denials reversed
Most-fought treatments for polysubstance use disorder
What insurers denied — and how those fights ended.
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment Center | 16 | 81.2% |
Typical time to a decision
11 days
Most land between 6 and 14 days
Handled as urgent
56.5%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Findings: The physician reviewer found that The patient’s parent has requested reimbursement and prospective authorization and coverage for any or all of the residential treatment center (RTC) level of care services. 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.
Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for structured 90-day residential treatment center (RTC) program, or in the alternative, 75 days of RTC services. The American Association of Community Psychiatrists Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services (ASAM 3.5). Findings: The physician reviewer found that American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient had no signs or symptoms of withdrawal after detoxification was completed. Given these findings, the patient meets ASAM 3.5 requirements for this dimension.For dimension 2, the patient had no medical problems.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided. Findings: The physician reviewer found that The records provided for review do not document that this patient has demonstrated post-acute withdrawal symptoms. There is no evidence that she has been a danger to herself or others, and she has not been aggressive or violent. She has been cognitively intact and not gravely disabled. There have been no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the residential treatment center (RTC) level of care.The member been medically and psychiatrically stable to the extent that she does not require the monitoring and supervision of a 24-hour facility to render the remainder of her care.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
How to use this in your appeal
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 polysubstance use disorder was denied, the published record says the denial is worth fighting.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.