Schizoaffective Disorder denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center services (equivalent to ASAM 3.5).At issue in this case is whether continued Residential Treatment Center (RTC) services (equivalent to ASAM 3.5) and services at issue were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A) to treat the enrollee’s mental health or substance use disorder.American Society of Addiction Medicine (ASAM) criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient underwent withdrawal management earlier in his treatment stay. The patient’s withdrawal needs could therefore be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications.

The patient has requested reimbursement and prospective authorization and coverage for RTC services (ASAM 3.1).Findings: The physician reviewer found that For Dimension 1, the patient’s intoxication and associated risk, withdrawal and associated risks, and addiction medication needs should be discussed and scored. The patient had used methamphetamines within hours before she was admitted to the RTC, and her urine toxicology was positive for alcohol, fentanyl, buprenorphine, and methamphetamine. The patient was placed on medications for detoxification including suboxone, clonidine, and propranolol. She reported cravings 8/10 for fentanyl.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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. 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 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.

An enrollee has requested authorization and coverage for continued stay at an inpatient psychiatric facility.The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, 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.For dimension 1- Risk of Harm. This dimension assesses potential for harm to self or others.

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