Drug Rehab Program denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services received for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue for this patient. The American Society of Addiction Medicine recommends placement based on a complex, individual, clinical assessment rather than “reimbursement limitations, program ideology, or utilization reviewers,” while the American Psychiatric Association recommend residential treatment “for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory sett…

The patient is a 17-year-old female has participated in a dual diagnosis partial hospital program due to polysubstance dependence, but continued to have problems with use of drugs, social issues, and poor recovery environment. The patient’s providers at the treatment facility have concluded the partial hospital program (PHP) is not sufficient for her treatment and recovery. The facility has recommended the patient be admitted to a 24-hour residential facility. The Health Plan reviewed the request and decided that PHP level of care was consistent with their guidelines and that residential level of care was not indicated.The current condition of the patient is that she continues to attempt to associate with older males who are drug users. She has comorbid psychiatric disorder, which has been diagnosed as bipolar disorder and is being treated with therapeutic levels of a mood stabilizer.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is a female with diagnoses of severe opioid use disorder, other severe stimulant dependence, bipolar II disorder, and generalized anxiety disorder. A review of the record indicates that the patient had prior treatment that included detoxification and residential treatment center (RTC) level of care treatment in 2012, 2014, and 2016. She reported relapse after these admissions. The patient was admitted on for detoxification with a plan to discharge her to the RTC program. She was medically cleared from detoxification. Physician progress notes indicate that the patient was calm and cooperative with clear and coherent speech. Her mood and her affect were euthymic. Her thoughts were goal oriented. She denied current suicidal and homicidal ideation. She reported previous thoughts of suicide with a plan to overdose in 2015.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center services for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. To objectively determine if the patient meets criteria for the services at issue, the Level of Care Utilization System (LOCUS) criteria has been used in this determination. This is an accepted, national standard for determining the appropriate level of care for adults. The patient met the following criteria: With respect to this patient’s risk of harm, the patient’s score is a 2, which correlates to low risk. The patient has a history of self-harm including burning herself and cutting herself. This behavior does not appear to be suicidal behavior.

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 Rehab Programwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.