Substance Abuse denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for an additional four months. 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. With regard to risk of harm, the records support a score of 4.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested reimbursement for intensive outpatient program (IOP) 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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for residential treatment center services provided from 6/28/18 going forward. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee’s depression, anxiety, and substance abuse. A review of the record indicates that the enrollee has been diagnosed with depression, anxiety, and substance abuse. In a report dated 6/29/18, the enrollee’s provider noted that the enrollee presented with a very low risk of suicide and that the enrollee was pleasant and cooperative. The enrollee stated that she had never had suicidal thoughts. The enrollee was alert and oriented with no evidence of disordered thinking.

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for residential treatment center services provided from 8/16/18 through 8/27/18. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the enrollee’s moderate major depressive disorder and substance abuse.At issue in this case is whether the requested residential treatment center services provided from 8/16/18 through 8/27/18 were medically necessary for treatment of the enrollee’s behavioral health condition.During the dates of 8/16/18 through 8/27/18, the patient showed cooperative behavior and treatment. The progress notes indicate that he was open and honest in regards to his feelings about his past substance use, his mood, and his anger towards his parents.

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