Residential Treatment Center Admission denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) admission to a residential treatment center (RTC) (ASAM Level 3.5) and (2) prescription Suboxone. Per American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC 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 has a history of addiction since age 15. He was stable on Suboxone for four and a half years until a breakup with his girlfriend.

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for admission to the residential treatment center (RTC) level of care for a duration of 90, 60, or 30 days.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.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary:The patient has been diagnosed with major depressive disorder, attention deficit/hyperactivity disorder, and posttraumatic stress disorder. The patient was admitted to a residential treatment center (RTC). The patient endorsed difficulties in school and had previously expressed suicidal ideation without a plan or attempts. The patient was reported to have made good progress. The records noted that she was cooperative and had an appropriate affect. Her risk of self-harm was noted to be low, and her risk of harming others was also low. Her suicide risk was rate rated as low. Her progress was noted to be good, and her suicide risk was noted to be low. The patient showed appropriate affect and was adherent to her medications. Her suicide risk was rated to be low. The patient’s treatment progress was noted to be good.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center substance abuse level of care. Findings: The physician reviewer found that in cases such as this an evidence based, objective, instrument such as the Level Of Care Utilization System (LOCUS) for psychiatric and addiction services is indispensable in determining medically necessary level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. The patient’s risk of harm is scored a 2 (low). The patient did not endorse suicidal ideation. Her functional status is scored a 3 (moderate). The patient exhibited fair to poor functional level, intact activities of daily living but a history of issues with school functioning due to substance use.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Residential Treatment Center Admissionwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.