Inpatient Detoxification denials in California external review

What the reviewers wrote

Where the denial was overturned

Standard Review Fulfills requirements of (1374.33) (h)(1)(A, B, C, D, G, H, I, K)Age: 44Gender: MNature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the adult substance use disorder inpatient detoxification services provided at The Betty Ford Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for inpatient detoxification services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient was placed on a suboxone taper and lorazepam taper for opioid withdrawal.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient detoxification services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether inpatient detoxification services that were received were medically necessary for the treatment of the patient’s medical condition. ECT involves inducing a controlled seizure in a patient. Sedatives like clonazepam prevent seizures. A patient taking significant doses of sedatives can therefore not achieve the seizures needed for ECT to be successful. The American Society of Addiction Medicine (ASAM) criteria is the most widely used and comprehensive set of guideline for placement, continued stay and transfer/discharge of patients with addiction and co-occurring conditions.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient detoxification services for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found that although inpatient detoxification services were indicated, the medical record does not demonstrate the necessity of the inpatient level of care for detoxification. Despite the concerning report of delirium tremens and seizure, the patient had no prior clinical treatment for withdrawal. During the hospital stay, he was treated with a chlordiazepoxide taper. The records show that two days subsequent to the patient’s last use of medication for withdrawal symptoms, the patient’s vital signs were stable and his mental status examination was reassuring. The patient was not psychiatrically distressed. His laboratory studies were essentially normal.

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for inpatient detoxification services for treatment of his alcohol dependence and alcohol withdrawal. Findings: The physician reviewer found that on admission, the patient’s physical examination was essentially within normal limits. The patient had an intact neurological examination, review of systems was described as unremarkable, and he was noted to be medically stable. Nursing notes indicate that he was fully oriented, neat and clean, and had no suicidal or homicidal ideation. He was described as anxious and cooperative. Group notes document that he described himself as happy and relaxed. Other progress notes indicate that he slept seven hours per night and ate all of his meals. He was described as coping well.

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 Inpatient Detoxification, then check the rights and deadlines that apply to your plan.