Drug Alcohol Behav Hlth Serv denials: what the review data shows
Independent reviewers have decided 14 published cases where an insurer denied Drug Alcohol Behav Hlth Serv — and they overturned the insurer 92.9% of the time. A denial for Drug Alcohol Behav Hlth Serv is a starting position, not a final answer.
Where the denial was overturned
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services, specifically ASAM Level 3.1. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met and continues to meet the Level 3.1 criteria for RTC services for the 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…
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (equivalent to ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient met and continues to meet the Level 3.1 criteria for RTC services for the 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…
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center services, specifically ASAM level 3.5. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for residential treatment center services for the time period under review. The ASAM criteria focus 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 li…
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Drug Alcohol Behav Hlth Servwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY