Case History #1
SS has a Blue Cross Gold Advantage PPO through California Choice Benefit Administrators, a fully-funded small group plan regulated by DMHC. Substance Use Disorder benefit: based on medical necessity.
$12,500.00 max out of pocket.
After deductible, pays 50% of billed.
Residential Treatment and Detoxification
Maximum per day of $650.00
Nothing has paid to date.
Anthem delay tactics include: "wrong billing code," "not a PPO policy”, “policy not regulated by California."
In each and every case, the Anthem rep says - check back in another 30-45 days.
She entered treatment on 9/18/21.
SS’s therapist wrote: We asked for additional days of residential treatment because SS currently has a very high relapse risk at a lower level of care due to her co-occurring disorder of Generalized Anxiety Disorder and Major Depressive Episodes (MDE). Her inability to cope with her depression and anxiety could pose an immediate threat of relapse. SS reports historically drinking and taking large amounts of pills to cope with her anxiety and depression, which helped short-term but increased her anxiety and depression long-term. SS's substance use disorder is complicated by anxiety, depression, and phase of life issues she has not processed. Her inability to cope with her anxiety could pose an immediate threat of relapse. It is imperative that she learn healthy coping tools and can emotionally self-regulate.
The peer-to-peer was done by Dr. G* from Prest & Associates. Prest did not disclose the license number or state of the peer-to-peer doctor, nor his/her medical expertise, but a search of the CMA website shows that he recently left Illinois and is now licensed in Lakewood, California (A61930) with no stated specialty. According to the CSAM website, he is not ASAM certified or certified by the American Board of Preventive Medicine in the subspeciality of addiction medicine.
SS’s therapist wrote: “Dr. G stated he follows ASAM criteria, but he did not focus on it. I went through dimensions 1-6 and highlighted notable criteria. I said we were still working on relapse prevention, disclosure of the extent of her pill usage, a problematic recovery environment, and the extremely high risk of relapse. I highlighted that this is SS's first-time seeking treatment for her long history of substance abuse and pain medication abuse and that she needs the full amount of time in treatment to properly discharge. Dr. G agreed and stated, "That's good that she is in treatment.”
To the therapist’s surprise a denial was then received from Dr. G, MD** (CA license _____) who according to an internet search is based in El Cajon, affiliated with Stanford HealthCare, and a graduate of USC. His specialty is general psychiatry and geriatric psychiatry. He is also listed on the internet as “Medical Director – Anthem”.
The Anthem letter says Dr. G#2, who never spoke with anyone at the treatment facility (therapist or CSAM doctor) denied additional days “after considering her health, health plan, clinical criteria or guidelines using ASAM criteria.” The letter also said that his decision “may also have used the latest information from proven research and medical journals during the review.” The very next sentence of the Anthem denial letter offered the client a free copy of the MCG (Milliman) Guidelines (used by psychiatrists for mental health patients and no longer allowed in California when assessing addiction patients).
REVIEW OF THE DENIALS BY Dr. Stephen Mohaupt, a psychiatrist who is also ASAM Board Certified:
Dr. G: focused on medical necessity
1. Medical necessity if the person is having acute symptoms from SUD and requires residential (risk of immediate danger due to relapse or continued use, a dangerous environment and severe problems functioning with daily life or
2. Person is DTO/ DTS (suicidal or homicidal) This is equivalent to requiring the highest rating in ASAM #5 (very severe) or the patient is actively suicidal or homicidal. ASAM #3: Very Severe. Their criteria did not seem to acknowledge ratings of the other 4 ASAM dimensions.
Dr. G#2: Denial reasons were copy and pasted from same template of Dr. M. The denial reasons list are generically written and there is not a reference to this specific patient or identify how the patient does not meet this criteria.
The reviewers did not consider the clinical items noted below: SS was high risk of relapse due to GAD and MDD (ASAM 3) which she had been self-medicating with alcohol. She was drinking and taking large amounts of pills to cope with Anx and Dep which helped short term. She was high risk of relapse (ASAM 5) due to long h/o severe use; with no identified coping skills also she was used to self-medicating to treat her Dep/ Anx (ASAM 3) which would need continued assessment and treatment.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. G has a 100% denial rate.
**According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. G#2 has a 92% denial rate.
Case History #2
Re: A fully-funded PPO Anthem plan administered by Collective Health; regulated by the DMHC.
SB entered treatment on 06/29/2020, 5 months before ASAM criteria became California’s standard and law for assessing treatment needs for addiction patients. We include her case to demonstrate that after ASAM criteria became law, nothing changed in terms of peer-to-peer reviews, as a pattern of unqualified doctors persisted.
ASAM criteria was utilized to assess and justify the clinical request for additional coverage. As this was the patient’s first experience in treatment, her lack of adaptive coping skills became clear in relation to her formal diagnosis of: Substance Abuse, Generalized Anxiety Disorder, Major Depressive Disorder, PTSD, and unresolved grief, all which pose a significant threat for sustainable sobriety.
Dr. G completed the peer review; Dr. G works for an organization called Prest & Associates; a Wisconsin based company. He is licensed by the Medical Board of California (A61930) and is reportedly based out of Lakewood. According to the CSAM website, he is not ASAM certified. According to the Medical Board of California, his area of practice is ‘internal medicine.’
SB’s therapist wrote: “He did not utilize ASAM. He seemed rushed, only asking if the client's daily living (ADLs) were ok, if she was suicidal or not, and if withdrawal symptoms had settled. He disregarded SB’'s high risk of relapse given her AUD, MDD, GAD, and PTSD.”
The written Anthem denial was “handled” by Dr. P**. According to the California Medical board, she is based in Encinitas and her license number is A100898. Her primary area of practice is psychiatry, and she is board certified in psychiatry and child & adolescent psychiatry. According to the CSAM website, she is not ASAM certified or certified by the American Board of Preventive Medicine in the subspeciality of addiction medicine.
The denial states “Dr. P. considered your health, your health plan, clinical criteria or guidelines, and may also have used the latest from proven research and medical journals during the review. “Your plan doesn’t cover this kind of care… You went to a residential treatment center for your alcohol use disorder(s). The program has asked to extend your stay. The plan clinical criteria considers this service medically necessary when one of the following is met. 1) the person is having acute symptoms from a substance use disorder and requires residential treatment (as show by the risk of immediate danger due to relapse or continued use, a dangerous environment, and severe problems functioning with daily life; or 2) the person is a danger to themselves or others…the information we have does not show you are a danger to yourself or others. For this reason, the request is denied as not medically necessary. We reviewed the request using the MCG Guideline Substance-Related Disorders.”
According to Summit Clinical Director Tyler Fitzgerald, LMFT, CATC-IV, Licensed Marriage Family Therapist #36390: “I believe Dr. P’s decision to send Shari home was not only premature but did not take into consideration the complex conditions she suffered from at the time, as well as the compounded effects resulting from a worldwide pandemic.”
“It appears Dr. P’s decision was based on an assessment by Dr. G who ignored Shari’s presenting psychiatric and psychological problems as well as the baseline understanding that isolation in early recovery is very dangerous. The patient lives alone without a support system.”
“Given this patient’s mental status on 07/08/20, it was incorrect for Anthem to deny her residential treatment authorization from 07/09/20 - 07/26/20. She did not have the necessary tools to return home and prevent herself from drinking. She clearly needed to continue treatment at a facility (Summit Estate Recovery Center) that is safe, controlled, and sterile with frequent monitoring. In addition, it was not feasible that Anthem discontinued her in-patient treatment as she continued to experience alcohol cravings with no one at her home to oversee and counsel her as to her actions, or for her to have to answer to. She was continuing to experience depression, anxiety, a general state of uneasiness, and dissatisfaction with life while suffering from PTSD. In addition, she suffers from Celiac disease, she had a prolapse of the Mitral valve of her heart, with a history of notable thyroid concerns. These issues caused her to be more susceptible to contracting COVID-19 given the integrity of her immune system.”
“All of these factors must be taken to consideration when evaluating or the result will not lead to an effective treatment approach. One condition occurring with another changes the way in which a patient responds; this patient has several conditions. It is also unclear what conditions Anthem’s doctors focused on as well as the criteria in which they used to justify their position.”
“The treatment that SB was receiving at Summit was lessening the frequency and intensity of her issues, therefore, during the pandemic, it was unquestionably premature to either discontinue or downgrade said intervention at that time. These are habits that her brain and body have been conditioned to now crave, and this behavior has been consistently and progressively repeated every day of her life over the past 2 years, accelerating when Santa Clara County ordered residents to “shelter in place.” It is then with reasonable probability that these issues cannot be resolved overnight, requiring the intervention that Summit Estate was providing with a higher concentration over the initial 6 – 12 months, and then with a lesser frequency and concentration thereafter, but, it is and will continue to be a lifelong endeavor for her.”
REVIEW OF THE DENIALS BY Dr. Stephen Mohaupt, an ASAM Board Certified psychiatrist:
Dr. G: seemed rushed and only asked about if the patients ADLs were OK and if she was suicidal or not and if withdrawal symptoms had settled. The ASAM dimensions were not addressed with these few questions above.
Dr. P: Stating care will only be covered if the person is having acute symptoms from SUD with a risk of immediate danger due to relapse or continued use, a dangerous environment and severe problems functioning with daily life or 2. Person is DTO/ DTS (suicidal or homicidal). It is important to note, this is equivalent to requiring the highest rating in ASAM #5 (very severe). Their criteria did not seem to acknowledge ratings of the other ASAM dimensions.
*Dr. G is a family doctor, licensed in California, working for Prest & Associates of WI. Dr. G is not a board certified ASAM doctor, nor certified by the American Board of Preventive Medicine (ABPM) in the subspecialty of addiction medicine under the American Board of Medical Specialties (ABMS).
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. G has a 100% denial rate.
** Dr P is a Child / Adolescent Psychiatrist, licensed in CA who works for Anthem.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. P has a 50% denial rate.
Case History #3
CO has a fully-funded CIGNA Open Access plan REGULATED BY DOI.
Substance Use Disorder benefit is based on medical necessity.
No deductible. $5000.00 max out of pocket. Pays 60-40% based on 110% OF MEDICARE .
He entered treatment on 5/5/22.
CO’s therapist wrote: CO was consuming 750 ml prior to treatment and has a history of suicidal ideation and seizures. Additional days were sought to improve self-regulation, solidify a relapse prevention plan, and have additional couples’ sessions in accordance with ASAM criteria.
DENIAL #1: CO’s therapist called the Cigna scheduling department at 5/23/22 2:06 PST and was on hold for 10 minutes before being prompted to leave a message to schedule a peer to peer review. Scheduling department returned the therapist's phone call at 3:34 PST and informed the therapist that peer to peer review would have to be completed by 9:00 AM PST the following day. Therapist requested an 8:30 AM peer review. Scheduler informed the therapist that the only time available was 7:00AM 5/24/22. Therapist accepted. Scheduling department informed the therapist that the review would be with Dr. R.At 7:05 AM, Dr. A* contacted therapist to complete the Peer-to-Peer review. Therapist asked Dr. A for his full name, and he only provided his last name. He agreed to use ASAM, he reported being licensed in California, and when asked if he practiced addiction medicine, he stated, "it's part of what I do".
Therapist went through the ASAM criteria 1-6 with a focus on sections 3,5, and 6. Therapist highlighted CO’s difficulty to self-regulate, struggles with relapse prevention plans, high relapse potential, a history of seizures, suicidal ideation, and resistance towards engaging his family in relation to his treatment. Dr. A asked if there were safety concerns regarding active suicidal ideation and therapist replied, "No active plan, no". Dr. A inquired about his medication including his Sertraline and Lamotrigine. Therapist provided insight for the medications. Dr. Afzal stated, "I have no more questions, thank you for your time" and terminated the call.
DENIAL#1: Dr. G, MD,** Medical Principal at Evernorth Behavioral Health, who is licensed in California (and 4 other states) as a psychiatrist, denied additional residential treatment. She wrote: Based upon my review of the available clinical information and the ASAM criteria, medical necessity is not met for continued stay at Level 3.5: Clinically Managed High-Intensity Residential Services (Adult Criteria) from 05/25/2022 forward, as you do not have function impairments that require stabilization in a 24-hour setting to prepare for community integration and continuing care. Less restrictive levels of care are available for safe and effective treatment. You do not have serious withdrawal symptoms. You have no medical issues needing around the clock care. You are not thinking about hurting yourself or anyone else. Your wife is supportive of your treatment.
DENIAL #2: Dr. C #1 ***, not Licensed in CA, a child psychiatrist, did the expedited review.
He said in a previous peer-to-peer that he is a Child Psychiatrist (wouldn't give me license number but said to check with Beacon who would not provide information). He said he does not work in addiction. He said he followed ASAM criteria for determination of medical necessity.This writer recognized Dr. C from a previous peer to peer review (he denied client JA on 9/30/21). The information I collected is below.
This expedited appeal took place one day after receiving a peer-to-peer denial. Dr. C contacted the therapist at 1:34 PST to complete the expedited appeal. Dr. C began the appeal by sharing the information he had on the client, including name, age, ethnicity, treatment history, reason for entering treatment, and treatment progress. Therapist confirmed the information. Therapist went through ASAM criteria 1-6 and highlighted mental health concerns, relapse potential/dangers, and recovery environment issues. Dr. C asked to follow up questions regarding any potential safety concerns and therapist explained that resident has struggled with Suicidal Ideation throughout his life. Dr. C took the time to explain that "there is no medical reason for continued residential stay" and highlighted that psychiatrically and medically, the resident has stabilized. Dr. C reported that there may be an additional level of appeal beyond this expedited appeal and to stay tuned for communication from the behavioral health company.
DENIAL#2: Dr. C#2, MD,**** Board Certified Psychiatrist, wrote: Based upon my review of the available clinical information and the ASAM criteria, medical necessity is not met for continued stay at Level 3.5: Clinically Managed High-Intensity Residential Services (Adult Criteria) from 05/25/2022 forward, as although you remain symptomatic, you are engaged in treatment, are medically and psychiatrically stable and have made gains in your recovery. You are less anxious and depressed, your appetite is improving, and your post-acute withdrawal symptoms are decreasing. In addition, you show insight into your substance use, can identify triggers to your use, and are using some of the healthy coping skills you need to remain sober. At this time, you are attending 12-step meetings and have developed a relapse prevention plan. Less restrictive levels of care are available for your continued safe and effective treatment.
REVIEW OF THE DENIALS BY Dr. Stephen Mohaupt, a psychiatrist who is also ASAM Board Certified:
Dr. A asked about if the patient had active suicidal ideation; the medications and terminated the call. Dr. C#2, Medical Director of Evernorth, Cigna's behavioral health department, asked about whether there were any safety concerns and concluded “there was no medical reason for continued residential stay.”
Both reviewers asked about safety concerns and suicidal ideation which is only one part of one ASAM dimension. The ASAM criteria includes 6 dimensions and the reviewers missed all of these. Dimension #5 is Severe; (poor coping skills) ASAM 3.5 level of care: Patient environment at home has communication difficulties identified by CO’s spouse along with COs historical inability to stop drinking or significantly reduce his alcohol intake make this environment provocative to relapse. If CO has a relapse he is at risk for a seizure which has serious and dangerous consequences. If unsupervised CO is at risk of relapse since he does not have effective coping skills and while he has a home to return to it is not supportive, CO and his spouse have not developed effective communication. CO’s spouse does not feel heard and identifies she cannot make CO do something.
* Dr. A. works for Prest & Associates. Dr. A is licensed in IL and NM as a Child & Adolescent Psychiatrist. Dr. A is not a board certified ASAM doctor, nor certified by the American Board of Preventive Medicine (ABPM) in the subspecialty of addiction medicine under the American Board of Medical Specialties (ABMS).
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. A has a 50% denial rate.
** Dr. G. MD, Medical Principal, Evernorth Behavioral Health, Inc. Licensed in CA (at a PA address), FL, AZ, AE, MS. PSYCHOSOMATIC MEDICINE - SECONDARY PSYCHIATRY - PRIMARY
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. G has a 100% denial rate.
*** Dr. C# 1 MD works for Beacon and Cigna. Dr. C# 1 admits to being a child psychiatrist but refuses to reveal the state where the medical license is issued or who they works for. Dr. C# 1 has done peer-to-peers for Beacon and Cigna, which also refused to provide information that would validate the doctor.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. C#1 has a 60% denial rate.
****Dr C#2, MD, Medical Principal, Evernorth Behavioral Health, Inc, Board Certified in Psychiatry.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. C#2 has a 100% denial rate.
Case History #4
GP has an Anthem of CA fully-funded small group plan regulated by DMHC.
Substance Use Disorder benefit based on medical necessity.
He is a 33-year-old professional male with 10+ years of alcohol abuse. GP was 10 months sober when he relapsed. He hid alcohol, and lied to his wife. Alcohol has negatively impacted his life in his relationships, marriage, malaise/motivation, and physical health. Client states he was a "functioning alcoholic." Liver enzymes are currently very high despite not drinking for over a week. He previously attempted treatment in 2016 which he completed. He has had therapy consistently for several years and maintains a weekly therapy appointment. Currently he is the Director of Hospitality for a family-owned business. No children. No history of suicidal ideation.
GP began residential treatment on 3/13/2021.
Additional days of residential treatment were requested in accordance with a review of ASAM Criteria because “GP continued to report post-acute withdrawal symptoms of "brain fog", Anxiety 7/10 and Depression 6/10 even with medication. GP's recovery is complicated by anxiety, depression and grief, and he did not have the tools to cope with them outside of a treatment facility at that time.
The peer to peer was done by Dr. T* on behalf of Prest & Associates. Dr. T and her employer, Prest & Associates, would not disclose where Dr. T is licensed and what is her medical specialty, but it was readily available on LinkedIn and the Wisconsin State Medical Board physician lookup. GP’s therapist wrote: Dr. T from Prest & Associates called at 11:30a.m. on March 23rd to do the peer-to-peer review on GP. This peer review was not a scheduled peer review. The therapist requested 15 minutes to review her notes. Dr. T denied the additional days requested and the last covered day of residential remains March 22nd.
A written Anthem template denial was signed by Dr. M,** a psychiatrist licensed in California. It is clear from Dr. M’s CV that he has not practiced addiction medicine since 2008 (prior to addiction being denied as an incurable brain disease). Dr. M’s denial reasons were copied and pasted from the same template Dr. G used to deny client SS: “The critical criteria consider this level of care medically necessary for those who meet all the following: 1) they do not have a medical condition that would interfere with treatment; 2) they need 24 hour care to increase motivation to change and 3) they are at high risk of harm and continued use without 24 hour care; and 4) their home or social situation is high-risk and unsupportive. The information we have shows your motivation and awareness have improved and your treatment can be managed in a lower level of care. According to the template, Level 3.5 ASAM guidelines were used (ASAM had become California law 9 months previously) while offering a free link to irrelevant MCG guidelines.
An expedited appeal done by the therapist with Dr. F** at 951-202-4961 license number CAG78239 on March 25th at 12:00 p.m. She said she would comply with ASAM criteria. No further RTC offered from 3/23/21. When asked, Dr F did not give a reason for the denial and instead stated that a letter will be sent out.
The same unsigned Anthem template used for denials said: “The critical criteria considers this level of care medically necessary for those who meet all the following: 1) they do not have a medical condition that would interfere with treatment; 2) they need 24 hour care to increase motivation to change and 3) they are at high risk of harm and continued use without 24 hour care; and 4) their home or social situation is high-risk and unsupportive. The information we have shows your motivation and awareness have improved and your treatment can be managed in a lower level of care. The Anthem denial template stated that the appeal had been reviewed using Level 3.5 ASAM guidelines but although ASAM has already become state law more than three months previously offered a free link to MCG guidelines.
REVIEW OF THE DENIALS BY Dr. Stephen Mohaupt, a psychiatrist who is also ASAM Board Certified:
Dr. T: reason for denial is not clear
Dr M and Dr. F: did not provide a reason for the denial
Letter sent indicated they used level 3.5 ASAM criteria. Based on the information of the telephone peer to peer it does not appear ASAM criteria were used.
From my review the patient has the following issues not considered by the reviewers.
ASAM #2: Poorly controlled medical condition of very high liver enzymes
ASAM #3; moderate Depression; Anxiety medications not working;
ASAM #5: Severe’ Poor skills to cope; 10+years alcoholism; 20 + past residential treatments.
ASAM #6: Living environment: was hiding alcohol from wife; relationship is strained and not clear to the degree.
*According to the Wisconsin state medical board Dr. T is a psychiatrist. According to their Linkedin page, Dr. T has been working for Prest & Associates for 9 years, performing “independent medical necessity and quality of care reviews for a URAC accredited IRO providing opinions for multiple commercial health plans, managed Medicaid and Medicare programs and state IRO level review.” URAC stated in a conference call with Summit and others that Prest is not accredited for peer-to-peer reviews. Additionally, Dr. T is not ASAM board certified nor certified by the American Board of Preventive Medicine (ABPM) in the subspecialty of addiction medicine under the American Board of Medical Specialties (ABMS).
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. T has a 83% denial rate.
**Dr. M is licensed in California as a psychiatrist who works for Anthem.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. M has a 100% denial rate.
** Dr. F is licensed in California as a Child & Adolescent Psychiatrist and a Forensic Psychiatrist who works for Anthem. Dr. F is not certified by ASAM.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. F has a 100% denial rate.
Case History #5
JW has a fully-funded 2021 ANTHEM Blue Cross PPO Classic Plan through a small employer.
It is regulated by DMHC.
Substance Use Disorder benefits are based on medical necessity.
The plan pays Anthem’s Maximum Allowed Amount for RTC and Detox of $1,000/day.
The maximum-out of-pocket $4000.
JW is a 37 year old head of video production with a history of alcohol use disorder which has become worse in the last 3+ years since she's been working from home due to Covid-19. She was drinking about a 6 pack of beer in the morning and afternoon and a bottle of wine at night which she seemed to be minimizing. She has some friends who were very supportive of her going to treatment. At first, she was very hesitant about going into detox and residential but understood she didn't qualify for IOP. She admitted she had tremors before drinking each day. She was terrified of going to treatment but knew she had to go because, as she said," I know this is a problem but it's the only thing that makes me feel ok [drinking] I don't want to live like this anymore. It's exhausting. She committed to going but was also afraid her boss would find out. and wants to deal with her HR company only. She has anxiety and depression but hasn't been diagnosed. Her mother died of a drug overdose and had a lot of sexual abuse in her life, her father was abusive and her grandmother committed suicide. She hasn't dealt with any of these things. The most sobriety she's had was approx 3 days to 1 week.
JW began residential treatment on 5/19/2022.
THE ANTHEM DENIAL
The therapist was informed of Resident’'s case going to a peer to peer review
on Tuesday 6/7/22 at 10 AM. When this therapist had not received communication to schedule the review he sent a follow up email Thursday 6/9/22 at 10AM to SERC insurance liaison. This therapist received a call and voicemail at 12:26PM on 6/9/22 from Dr. R*, Psychiatric peer reviewer from Prest. This therapist was unable to return the call due to being in session. This therapist received a second call from Dr. R at 2:16 PM and again was in a meeting. This therapist returned Dr. R’s call at 2:35 PM and Prest scheduling department answered. This therapist attempted to schedule a peer review but Prest informed this therapist that "Anthem stated this review must be completed within 55 minutes". This therapist responded: , "Just put me through to him then". This therapist was connected to Dr. R. This therapist remembered Dr. R from a prior case and thus didn't ask the introduction questions. inquired about Resident’s physical and mental state. This therapist went through JW’s ASAM criteria with a focus on her hallucinations during her detox period, her labile moods and issues processing past trauma, her high depression and anxiety, her past drinking habits and sustaining injuries/ having seizures due to alcohol, and her changing recovery environment with her plans to move out of San Francisco. Dr. R inquired about her discharge plan and the therapist informed him of her plan to move out of the city, seek support from her friend group, and continue treatment with an IOP program. Dr. R asked about the amount of days requested and this therapist stated the 6/15/22 anticipated discharge date. Dr. R thanked this therapist for the time and terminated the call. The call lasted 5 minutes in duration.
Dr. N**, a psychiatrist specializing in geriatric and forensic psychiatry,
used an Anthem template to deny. The template says : “The clinical criteria considers this level of care medically necessary for those who meet all the following: 1) they do not have a medical condition that would interfere with treatment; 2) they need 24 hour care to increase motivation to change and 3) they are at high risk of harm and continued use without 24 hour care; and 4) their home or social situation is high-risk and unsupportive. Get a Free Copy of the Criteria and MCG Guideline.
He added: The information we have shows that you are able to care for your
daily needs. You are actively participating in treatment. You expressed motivation for sobriety. You are not experiencing any physical or mental health symptoms that require 24-hour care. You are not prescribing medications that require this level of observation. For this reason, the request for you to remain in residential rehab is denied as not medically necessary. There may be other options to help you continue your treatment, such as a partial hospitalization program, intensive outpatient program or other services. We based this decision on ASAM criteria, 3rd Edition Adults Clinically Managed High Intensity Residential services.
The expedited appeal was done by Dr. G***, an adult psychiatrist
licensed in California. He stated: "I've worked in addiction" but declined to provide additional details. The therapist placed the call to Dr. G (MD) at 3:00 PM PDT. Dr. G answered and the therapist confirmed resident identification.
Therapist asked Dr. G if ASAM standards would be used today and he confirmed.
Therapist asked Dr. G if he were licensed in California and had experience working in addiction. Dr. G stated he had but would not provide additional details on his addiction experience. Dr. G asked for justification for continued treatment. Therapist provided Dr. G with information regarding Resident not wanting to attend aftercare (IOP), poor recovery environment, relapse risk, motivation, etc. (dimensions 3, 4, 5 and 6). Dr. G asked questions about Resident’s reasons for not wanting IOP. Therapist explained how CT was overconfident about her ability to remain sober just because of RTC. Therapist reminded Dr. G of Resident's drinking history as well as her propensity for injury when intoxicated. Dr. G stated she would discharge and do outpatient treatment. Writer explained, again, that Resident was did not believe she needed additional treatment at this time and the additional few days of RTC was needed to allow her to come to that conclusion on her own as she did not respond to pressure. Therapist also explained that Resident was not open to attending recovery meetings. Dr. G stated she should attend PHP. Therapist again reminded Dr. G that she was not willing to do IOP so why would she do PHP. Therapist explained that Resident lives alone in an apartment in San Francisco where her support group drinks heavily.
Dr G. stated, "Well, I see she needs treatment but this is not that kind of discussion. This is to determine payment".
On Jun 11, 2022 Dr. G sent a written denial based not on ASAM criteria,
which is mandated in California since January 1, 2021 but on the Medical Necessity definition found on page 157 of the Motive Technologies Anthem Classic PPO 250/20/10 Evidence of Coverage booklet under the Definitions section.
REVIEW OF THE DENIALS BY Dr. Stephen Mohaupt, a psychiatrist who is also ASAM Board Certified:
It is clear what ASAM Level of Care 3.5 tells us about JW
JW needs 24 hour supportive addiction treatment.
Her environment is provocative to relapse.
There is a likelihood of relapse with dangerous consequences.
JW cannot go unsupervised.
*Dr. R is a psychiatrist who works for Prest & Associates. He is licensed in California. He is not credentialed by ASAM or ABPM.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. R has a 100% denial rate.
**Dr N is a psychiatrist specialized in geriatrics and forensics. He is a California licensed psychiatrist working for Anthem.He is not credentialed by ASAM or ABPM. He has a 38% denial rate according to the SB 999 California Scoreboard.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. N has a 38% denial rate.
*** Dr. G is licensed in California as a Geriatric Psychiatrist who works for Anthem. He is not credentialed by ASAM or ABPM. . He currently has a 85% denial rate according to the SB 999 California Scoreboard.
*According to the Scoreboard 51 CA facilities have kept since November 2021, Dr. G has a 85% denial rate.