Residential Treatment Center Level Of Care denials in California external review
In the California DMHC record, independent physician reviewers decided 30 published external-review cases involving Residential Treatment Center Level Of Careand overturned the plan’s denial in 70%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Residential Treatment Center Level Of Care denials
| Category | Decisions | Overturned |
|---|---|---|
| Alcohol Use Disorder | 7 | 71.4% |
| Substance Use Disorder | 6 | 83.3% |
| Depression | 4 | 75% |
| Adhd | 4 | 50% |
| Bipolar Disorder | 4 | 75% |
| Anxiety | 4 | 75% |
| Post-traumatic Stress Disorder | 3 | 66.7% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage/reimbursement for any, or all, of the residential treatment center (ASAM 3.1) level of care services. Findings: The physician reviewer found thatPer American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for residential treatment center 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 did not have symptoms of withdrawal following the completion of detoxification.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for any or all of the the residential treatment center level of care services. The researchers have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument is a standardized tool used to determine the intensity of services needed for children and adolescents, 6-18 years of age, presenting with psychiatric, substance use, medical and/or developmental concerns. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) (ASAM 3.5) level of care services. Findings: The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC level of care 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 did not have any symptoms of withdrawal.
Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) (ASAM 3.1) level of care. Findings: The physician reviewer found that For Dimension 1, the patient’s intoxication and associated risk, withdrawal and associated risks, and addiction medication needs should be discussed and scored. Here, the patient has no signs or symptoms of intoxication or withdrawal, and he is not taking addiction medications. His last drink was approximately six months prior. His vital signs are stable. His admission withdrawal scales were expectedly very low. Risk Rating = 0.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Center Level Of Care, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY