Residential Treatment Care denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that a patient has requested reimbursement for residential treatment care (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive, and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment care. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In this case, substance use dominated the patient’s daily routine while he had tried and failed an array of therapeutic interventions. One day prior to the disputed timeframe, the patient had significant craving and dreams of substance use. He was depressed and evasive, and had poor insight. Two days later, the patient was prescribed, but did not take, an anti-craving medication, Naltrexone. Later that day, he met with a psychiatrist. There was concern for social anxiety, but the patient was diagnosed with unspecified depressive disorder. The provider recommended duloxetine, but the patient declined the trial. However, gabapentin was increased.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any of the residential treatment care (RTC) (ASAM Level 3.5) services. Findings: The physician reviewer found that American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC services from 8/16/21 and forward. 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 managed with naltrexone for cravings. The patient’s withdrawal needs were safely managed in a Level 3.5 setting.

Nature of Statutory Criteria/Case Summary: The parent of a 13-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment care for treatment of the enrollee’s behavioral health condition. Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C).Findings: The physician reviewer found that there is a lack of support in the medical literature for the services at issue. Overall, it appears that most of this patient’s functional issues were due to his impulsive behaviors and substance use. Based on the records, the RTC admission was due to his oppositional defiant disorder (ODD) diagnosis. The evidence based literature regarding children’s mental health treatment has shown that treatment outside of a residential setting is effective and appropriate and is as beneficial as RTC programs.

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 Treatment Care, then check the rights and deadlines that apply to your plan.