Post-traumatic Stress Disorder denials in California external review
In the California DMHC record, independent physician reviewers decided 363 published external-review cases involving post-traumatic stress disorderand overturned the plan’s denial in 67.5%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for post-traumatic stress disorder
| Treatment | Decisions | Overturned |
|---|---|---|
| Residential Treatment Center | 174 | 81.6% |
| Partial Hospitalization Program | 27 | 70.4% |
| Intensive Outpatient Program | 20 | 65% |
| Eye Movement Desensitization And Reprocessing | 17 | 52.9% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 357 | 68.6% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 0% |
What the reviewers wrote
Where the denial was overturned
Findings: The physician reviewer found that The patient requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC services. ASAM criteria focuses on 6 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.
Nature of Statutory Criteria/Case Summary: Patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 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 was tapering off methadone with the plan to switch over to Suboxone for medication assisted treatment and was experiencing withdrawal during her stay at the RTC including cramping and diarrhea.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: Patient requested reimbursement for RTC services (ASAM 3.1). Per the ASAM criteria, this patient doesn’t meet all six Level 3.1 criteria for RTC services. ASAM criteria focus on 6 dimensions to determine the appropriate level of care: For dimension 1 (intoxication & withdrawal potential), patient meets ASAM 3.1 as patient didn’t have any symptoms of acute withdrawal. On the date of denial, patient’s vital signs were stable, & he was being treated in level 3.1 RTC. For dimension 2 (biomedical conditions), patient meets ASAM 3.1 as patient had no acute medical illness. Thus, patient’s biomedical problems, if any, have been stable & don’t require medical or nurse monitoring, & patient has been capable of self-administering any prescribed medications.
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for RTC services from 7/28/22 forward. The 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 no longer had withdrawal symptoms per the records. The patient’s withdrawal needs can be safely managed in a Level 3.5 setting.
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.
A diagnosis does not by itself establish treatment intensity. See the separate record for residential, PHP, IOP, inpatient, and withdrawal-management denials: behavioral-health level-of-care evidence guide.
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 post-traumatic stress disorder, 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