Psychotic Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center (RTC) services (equivalent to ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 criteria for RTC services for the time period under review. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and associated risk, withdrawal and associated risks, and addiction medication needs; (2) biomedical conditions including physical health concerns and pregnancy-related concerns; (3) psychiatric and cognitive conditions and history including active psychiatric symptoms and persistent disability; (4) substance use-related risks including the likelihood of engaging in risky substance use and the likelihood of engaging in risky substance use disorder-related behaviors; (5) re…

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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 focus 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 did not have any symptoms of acute withdrawal after completing detoxification services and was being treated in level 3.1 RTC. Given these findings, the patient meets ASAM 3.1 requirements for this dimension.

Where the denial was upheld

The parent of a 17-year-old male enrollee has requested mental health outpatient psychotherapy visits for treatment of the enrollee’s psychotic disorder and rule out chronic schizophrenia, paranoid type. Findings: The physician reviewer found that the medical literature is clear that the primary treatment for both positive and negative symptoms of schizophrenia is medication. From the records provided for review, it appears that the patient has not had an adequate trial of medication. This treatment would include consistent administration over a period of months of an anti-psychotic medication in therapeutic dosages. This plan would also include trials of several different medications if the initial choice had unacceptable side effects or failed to be efficacious. Additionally, a mood stabilizer is often added to enhance the efficacy of treatment.

The parent of a 17-year-old male enrollee has requested a diffuse tensor imaging study for evaluation of the enrollee’s severe cognitive deterioration. Findings: The physician reviewer found that in this patient’s case, the use of diffusion tensor imaging would not lead to any change in therapy or add information that would prove useful to his therapeutic team. If diffusion tensor imaging study demonstrated changes consistent with traumatic brain injury, these findings would not change the approach to treatment of the patient’s underlying psychotic disorder. Use of diffusion tensor imaging is not within the standard of care for a patient with either traumatic brain injury or psychiatric disease and is therefore not medically necessary.

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 psychotic disorder was denied, the published record says the denial is worth fighting.