ETOH Rehab Program denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 45-year-old female with a long-standing history of alcohol and cannabis dependence. She was admitted to inpatient treatment in June 2006 with a history of drinking 18 ounces of hard alcohol and a bottle of wine per day for the past 10 years and smoking marijuana every day for the past 30 years. Her relationship with her significant other was also noted as spiraling downward. The patient noted that her drinking had led to mood swings and much anger. She had also been referred to anger management class due to hostility. Family history was notable for alcohol dependence of her father and her mother who was described as “crazy,” but no other details are known. During her treatment the patient received Risperdal and Campral. She was also treated with a Librium protocol for detoxification from alcohol.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center (RTC) services. The submitted documentation supports the medical necessity of both the services at issue and the requested services going forward. The American Psychiatric Association treatment guidelines for Substance Use Disorders recommends that residential treatment, or similar care higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A 46-year-old female enrollee has requested reimbursement for emergency services as defined in Health and Safety Code Section 1317.1, subdivision (a)(2)(A). The patient is a 46-year-old female who has been diagnosed with major depressive disorder, unspecified eating disorder, and alcohol use disorder in sustained full remission. She had no reported history of hospitalization prior to the disputed service and there was no known history of suicidal behavior. In addition to pharmacotherapy consisting of citalopram, bupropion, clonazepam, lamotrigine and lithium, the patient had also been treated with outpatient therapy. In the months prior to admission, the patient reported depressive symptoms including low mood, guilt, anxiety, poor focus and decreased energy with a desire to stay in bed all day and an inability to get things accomplished.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollee’s behavioral health condition. Findings: The physician reviewer found that based on the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) criteria to determine the appropriate levels of care the patient scored 19 meeting criteria for an intensive outpatient program. The patient’s risk of harm score is three (3), moderate risk of harm. The patient had an overdose. The documentation reports that the patient did not know if the overdose was a suicide attempt or not. She had no reported prior suicide attempts. The patient denied any suicidal ideation. The documentation reported that the patient’s provider felt that the patient was a low acute suicide risk.

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 ETOH Rehab Program, then check the rights and deadlines that apply to your plan.