Residential Substance Abuse Treatment denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 50-year-old male with a 35-year history of alcohol abuse. Prior to his admission to substance abuse treatment the patient was drinking on the order of two to three bottles of wine per sitting, typically drinking three to four times per week, in addition to periodic use of marijuana. The latter involved one joint per day, last on 6/1/04, and the submitted notes indicate the patient last drank two bottles of wine, two beers, and three cocktails on 6/22/04 prior to entering residential treatment on 6/25/04. The patient noted a very fractious relationship with his wife; a divorce was soon to be finalized due to his extramarital affairs. In addition, the patient had a history of yelling at his wife and their two children quite a bit and pushed his wife on occasion.

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the residential substance abuse treatment services provided from 4/25/18 through 5/18/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patient’s behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association treatment guidelines for substance use disorders recommends that residential treatment 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, 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: An enrollee has requested reimbursement for residential substance abuse treatment for treatment of the enrollee’s behavioral health conditions. Findings: The physician reviewer found the patient presented to the residential treatment center with a history of alcohol use disorder. He expressed motivation for his treatment and presented on a voluntary basis. During treatment, he was noted to be cooperative and calm, and breathalyzer evaluations indicated that he did not relapse during treatment. He was also noted to show insight into his illness. The progress notes did not document psychosis, paranoia or mania symptoms during the residential treatment stay. He had depression and anxiety that were both noted to be mild. The records did not indicate severe symptoms that would require intensive psychiatric care.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential substance abuse treatment level of care services. Per Addiction Medicine criteria, this patient does not meet Level 3.5 criteria for residential substance abuse treatment level of care services. The 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 has not had any symptoms of withdrawal after she completed detoxification services.

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 Residential Substance Abuse Treatment, then check the rights and deadlines that apply to your plan.