Substance Abuse Disorder: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents 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) developmental, medical, substance use 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.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive outpatient program (IOP) treatment with specific services including specialized treatment for co-occurring psychiatric and substance abuse disorders, individual therapy sessions, support on the weekends, 16 available hours of groups weekly, services with licensed therapists (not non-licensed intern therapists), family support sessions, clinical staff that is available 24-hours per day in the event of a crisis, staff that is equipped to refer an individual to emergency services and support of the family in the event of a crisis, large peer group meetings to assist in expanding social and emotional resources, sober fellowship activities, Alcoholics Anonymous (AA) meetings, and strict monitoring of social activities by eliminating social media use and eliminating conta…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the residential treatment center (RTC) services provided, partial hospitalization program (PHP) level of care provided, and intensive outpatient program (IOP). Findings: The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, the records provided for review do not support the medical necessity of the residential treatment center (RTC), partial hospitalization program (PHP) and intensive outpatient program (IOP) levels of care services provided to this patient during the period under review. The patient had reported symptoms of nausea, vomiting, headaches, and a sensation of cloudiness. However, there was no evidence of suicidality or homicidality, he did not appear to be manic, psychotic, or delusional, and he was medically and psychiatrically stable.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for dual diagnosis residential treatment services provided. Findings: The physician reviewer found that the patient was not at imminent risk for severe withdrawals and his post-acute withdrawal symptoms were mild. He was not a danger to himself or others, and he did not demonstrate self-harm urges or behaviors. There were no emotional, behavioral, or cognitive issues warranting residential services. He was not psychotic or delusional. He was not impaired such that he could not perform his activities of daily living. There were no new problems that arose. He was making progress, was motivated, and engaged in his treatment plan.

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