Mental Health Treatment denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center services (ASAM 3.1). Per the American Society of Addiction Medicine criteria, this patient meets Level 3.1 criteria for some of the RTC services. The ASAM criteria focus on six dimensions to determine the appropriate level of care. Admission to ASAM Level 3.1 is driven by multiple limitations across dimensions 3, 4, and 5.For dimension 1, the patient had no signs or symptoms of intoxication or withdrawal and was not taking medication-assisted treatment. Risk Rating=0. Based on these findings, there were no specific withdrawal or intoxication needs present during the period under review. For dimension 2, the patient’s biomedical problems, in this case, the patient did not express any physical symptoms. Risk Rating=0.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focus 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 did not have any symptoms of acute withdrawal after completing detoxification services and was being treated in Level 3.1 RTC. Given these findings, the patient meets ASAM 3.1 requirements for this dimension.

Where the denial was upheld

Nature of Statutory Criteria: The patient has requested reimbursement for RTC services (ASAM 3.5).For Dimension 1 The patient was not intoxicated upon admission and his urine toxicology was positive for cannabis. The patient was placed on medications for detoxification including phenobarbital, Lorazepam, Zofran as needed for nausea, and Seroquel as needed for sleep. The patient had last used alcohol six days prior to admission, cannabis 10 days prior to admission, and benzodiazepines seven days prior to admission. Overall, the patient was experiencing or anticipated to imminently experience mild to moderate signs and/or symptoms of intoxication that could have been addressed in any level of care as needed and thus did not require a medically managed addiction treatment program for intoxication management. Given these findings, the patient meets ASAM 3.5 requirements for this dimension.

Nature of Statutory Criteria/Case Summary: Patient requested reimbursement for RTC services (ASAM 3.1). Per the ASAM criteria, this patient doesn’t meet all six Level 3.1 criteria for RTC services. ASAM criteria focus on 6 dimensions to determine the appropriate level of care: For dimension 1 (intoxication & withdrawal potential), patient meets ASAM 3.1 as patient didn’t have any symptoms of acute withdrawal. On the date of denial, patient’s vital signs were stable, & he was being treated in level 3.1 RTC. For dimension 2 (biomedical conditions), patient meets ASAM 3.1 as patient had no acute medical illness. Thus, patient’s biomedical problems, if any, have been stable & don’t require medical or nurse monitoring, & patient has been capable of self-administering any prescribed medications.

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 mental health treatment, then check the rights and deadlines that apply to your plan.