Substance Use Disorder denials at external review

• rising

  It has risen over the published record: 72.7% in 2021 against 97.7% in 2025. What drove that is not in this data — the file holds outcomes, not who chose to appeal or how plans changed their own review.

• most-cited standard

  Reviewers named American Society of Addiction Medicine more than any other standard here — 330 decisions, which came out at 82.4%. Citing a standard and the outcome share a cause; this is not the effect of naming it.

California requires each published decision to carry “a detailed case summary that includes the specific standards, criteria, and medical and scientific evidence, if any, that led to the case decision” (Health & Safety Code § 1374.33(h)(1)(K)). These are the elements our extraction found in this class, split by how the decision came out.

Read as description, not instruction. These are patterns in what reviewers wrote, not steps to follow, and no combination of them predicts an outcome. Only codes that cleared the validation gate appear — thirteen did not.

• American Society of Addiction Medicine82.4%330
• LOCUS family—22
• American Academy of Child and Adolescent Psychiatry—12
• FDA—1

A rate here is the outcome of decisions that named the authority, not the effect of naming it. Reviewers cite the standard they applied; the citation and the outcome share a cause.

• Mental Health82.5%365
• Pharmacy—3
• Diagnostic imaging & screening—1

Browse all treatment classes · Pick your own pair

• RTC82.6%351
• Partial Hospital—6
• Intensive Outpt Prog—4
• Acute Psych—3
• Opioid Dependence Rx—2
• CT Scan—1
• Individ Counsel—1
• Pain Medication—1

• Medical Necessity82.3%368
• Experimental/Investigational—1

Medical-necessity review asks whether the care is needed. Experimental/investigational review asks whether it is likely to be more beneficial than standard therapy — a harder statutory test, and the rates show it.