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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center level of care.  Findings:  The physician reviewer found that applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.5 criteria for Residential Treatment Center services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient still had post-acute withdrawal syndrome (PAWS) symptoms of agitation, anxiety, insomnia, and tremors. Based on clinical findings, the patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient did not have any current medical problems. The patients biomedical problems were therefore stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient had a diagnosis of schizophrenia. He had significant paranoia and delusions. His symptoms of psychosis may have been exacerbated by heavy cannabis usage. The patient was also trying to manage his auditory hallucinations and paranoia with kratom and benzodiazepines. He was unable to control his impulses to use substances due to the severity of these symptoms. The patient was feeling passively suicidal on admission due to living with auditory hallucinations and paranoia. He participated in groups and had medication adjustments of his psychiatric medications. The patients mental status was sufficiently stable to permit participation in the therapies provided in the residential treatment center, and he demonstrated a repeated inability to control impulses to use drugs and was in imminent danger of relapse. The resulting level of dysfunction was of such severity that it precluded participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program.For dimension 4 - Readiness to Change. The patient was admitted voluntarily, as he was unable to stop using cannabis, kratom, and benzodiazepines. The patient had been using them on a daily basis for the past two years. The patient's perspective impaired his ability to make behavior changes without the repeated, structured, and clinically directed motivational interventions which could only be delivered in a 24-hour milieu.For dimension 5 - Relapse, Continued use, Continued Use, or Continued Problem Potential. The patient had been in a relapse for the past two years, as he had been trying to manage paranoia and hallucinations with these substances. He had been started on antipsychotic medication but was continuing to be delusional and had significant distress from these symptoms. The patient did not have full insight into his psychotic symptoms or how they triggered his use of substances. He endorsed passive suicidality due to paranoia and auditory hallucinations. The patients psychiatric condition was stabilizing, however, he was unable to control his use of substances and had limited ability to interrupt the relapse process. His substance usage posed an imminent danger of harm to himself or others in the absence of 24-hour monitoring and structured support.For dimension 6 - Recovery Environment. The patient was living with his brother and was unemployed due to his psychosis and substance usage. He did not have supportive friends and was socially isolated. The patient's social network was characterized by significant social isolation or withdrawal, such that recovery goals were inconsistently unachievable at a less intensive level of care. The patient was unable to cope, for even limited periods of time, outside of 24-hour care.Using the ASAM level 3.5 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.5 treatment. Accordingly, the Residential Treatment Center level of care services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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.