Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for RTC services. The records document that the patient has received high-intensity residential treatment services (equivalent to ASAM Level 3.5). 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 had mild withdrawal symptoms. The patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient has no reported medical problems. The patients biomedical problems, if any, are stable and do not require medical or nurse monitoring. For dimension 3, the patient reported depressive and anxiety symptoms. She has struggled with guilt, irritability, and anxiety. She has not been suicidal or homicidal. She was diagnosed with post-traumatic stress disorder (PTSD) and bipolar disorder in the facility and started on medications. There are no noted functional deficits. She has participated in groups. The patients mental status has been assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. However, she does not meet any of the other qualifying criteria including unable to control his use of alcohol and drugs with attendant probability of imminent danger, or demonstrates repeated inability to control her impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, or demonstrates antisocial behavior patterns, or has significant functional deficits, which are likely to respond to staff interventions, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 4, the patient admitted herself for treatment voluntarily due recognizing that her drinking was out of control. She has participated in treatment. However, the patient does not have limited insight and little awareness of the need for continuing care or marked difficulty in understanding the relationship between her substance use and impaired coping skills and level of functioning. She does not demonstrate opposition to addressing the severity of her addiction problem or require structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care. The patients perspective does not impair her ability to make behavior changes without repeated, structured motivational interventions, and she does not express little to no interest in changing. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 5, the patient endorsed drinking a pint daily for the past two years and also using cannabis daily. Previously, the patient used Xanax daily, but she stopped in November 2020. She previously used cocaine several times per month, but she stopped in January 2021. This was the patients first attempt at treatment. She has no suicidal or homicidal ideation. The patient does not meet criteria of lacks insight into benefits of continuing care, unable to control use of alcohol or drugs with attendant probability of harm to self or others or is in imminent danger of relapse as a result of a crisis situation, or despite recent active participation in treatment at a less intensive level of care, the patient continues to use alcohol or drugs, or demonstrates a lifetime history of repeated incarceration. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 6, the patient lives with her stepmother and sister in a sober household. The patients family is supportive. She works occasionally and has support from the community. The patient does not meet criteria of living in an environment characterized by a moderately high risk of neglect, abuse or substance use so endemic that the patient is assessed as being unable to achieve or maintain recovery at a less intensive level of care, or social network includes regular users of drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care, or patients social network is characterized by significant social isolation and withdrawal, such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care, or patient's social network involves living with an individual who is a regular user, addicted user, or dealer of alcohol or other drugs, or patient is unable to cope, for even limited periods of time outside of 24-hour care. Based on these findings, the patient does not meet the requirements for this dimension. The ASAM guidelines require adult patients to meet all six dimensions to support RTC services. This patient does not meet ASAM Level 3.5 RTC criteria for dimension 3, 4, 5, and 6. Therefore, the RTC services were not and are not medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.