Appeal type: Medical Necessity
Decision: Overturned 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 meets Level 3.5 criteria for RTC services. 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 underwent withdrawal management earlier in his treatment stay. The patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient has hepatitis C. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has a long history of opioid use disorder and methamphetamine use disorder. The patient endorsed use of 1 gram of intravenous methamphetamine and 1 gram of intravenous heroin daily for 15 years. He has survived seven overdoses on heroin and has needed Narcan to be resuscitated. He has ongoing difficulty with delaying gratification and impulse control due to his chronic addictive disorder. The patient recently left a previous RTC in March 2021 against medical advice, he relapsed, and was incarcerated. The patient smuggled drugs intrarectally into the facility and he was caught using during the course of his treatment. 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. The patient demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction is so severe that it precludes the patients participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted voluntarily due to legal problems related to his opioid and methamphetamine addiction. The patient has served several years in custody due to legal issues related to his substance use disorders. He is in precontemplative stage of change. He minimized the importance of his substance use disorders and he has failed to take full responsibility for his behaviors that include using drugs and driving while impaired. He also brought cannabis into the treatment facility and then did not take responsibility even when confronted with the evidence. He has a history of multiple drug-related charges. The patient demonstrates antisocial behavior patterns that have led to significant criminal justice problems, lack of concern for others, and extreme lack of regard for authority, which prevents movement toward positive change and precludes participation in a less structured and intensive level of care. Despite recognition of a substance use or addictive behavior problem and understanding of the relationship between his substance use, addiction, and life problems, the patient expresses little to no interest in changing. Because of the intensity or chronicity of the patients addictive disorder and high-risk criminogenic needs, he is in imminent danger of continued substance use or addictive behavior. This poses imminent serious life consequences and a continued pattern of risk of harm to others, while under the influence of substances. For dimension 5, the patient has been using 1 gram of heroin and 1 gram of methamphetamine on a daily basis for the past 15 years. He has a significant history of repeated incarcerations related to his drug usage. Most recently, he was arrested and smuggled drugs into the facility in his rectum such that he sustained a seizure. He has a history of multiple overdoses on heroin. He admits to using substances and crashing his vehicle on more than one occasion. The patient demonstrates a lifetime history of repeated incarceration with pattern of relapse to substances and uninterrupted use outside of incarceration, with imminent risk of relapse to addiction and recidivism to criminal behavior. This poses imminent risk of harm to self or others. The patient's imminent danger of relapse is accompanied by an uninterrupted cycle of relapse-reoffending-incarceration-release-relapse without the opportunity for treatment. The patient requires 24-hour monitoring and structure to assist in the initiation and application of recovery and coping skills. For dimension 6, the patient is homeless and not allowed to stay with his family due to his past behaviors. He has significant legal issues and is court-ordered to treatment. He has not been able to maintain sobriety when released from the residential level of care. His girlfriend also uses heroin and is pregnant. His social network consists of drug dealers and other users. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the RTC services for substance abuse disorder, specifically ASAM Level 3.5, were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.