help please

[chromedome]

What is the name of your state? California

My son is a methamphetamine addict. I contacted my HMO-Cigna and they explained the substance abuse benifits my plan includes. There are 3 levels. Intensive out patient, day treatment, and in patient. They provided me with the network facilities available to me. I contacted one and arranged for him to be evaluated. After the evaluation, the clinical evaluation was sent to cigna to determine the level they would authorize. The review recommended in patient treatment. However, cigna denied that and authorized day treatment. They said he did not meet the criteria for in patient. Some of the criteria was that he did not have a medical condtion, ie: hypertension, abnoraml liver panel, which warranted full time observation. Another criteria was that he has not been treated in the past for this addiction. They felt he may benifit from this lower level. They explained that should that treatmeent not be successful (meaning his addicition continued and he used meth again) he would then be put into a higher level of care(in patient). My son is 18 not 40. Fortunately, other than this addicition he has not suffered any medical problems like hypertension, etc.

I know he will not benifit from the level they authorized and needs the inpateient care. I also argued that if he failed at this lower level it could mean his life. This is methampohetamine, not alcohol or marijuana. Failure with meth could mean an overdose and death, ot simple getting drunk or high.

When I argued this they told me that the inpatient was not a lock down type and therefor he could just leave if he wanted. The implication is that it was the same as day treatment in that he could come and go. Yet, the contradciion is that they admit that in patient is a better level of treatment and I say,therefor it cannot be the same. Do I have to wait for my son to fail and die or suffer permanaent brain damage before they authorize better care?

I need to get him into the in patient to save his life. What can I do? What legal action can I take immediately to do?

[purple2]

If this situation wasn't so sad, it would be laughable that the insurer thinks he can be treated on an outpatient basis. In my experience, a person in your son's situation needs to be in a 24 hr restrictive environment to prevent him from getting drugs. 1st consider finding a different hospital that does have a lockdown, close supervision program.

He can receive inpatient care. Your insurance company is not denying him care, they are just declining to pay for it.

If the situation is that dire, consider helping him to get hospitalized and deal with the payment issues 2nd.

Your insurance policy outlines how to file an appeal of their decision. Look into additional insurance options for him, ie Medicaid, to use during his recovery. The hospital should have a financial counselor to help identify other insurance/payment options.