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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) subacute detoxification (ASAM Level 3.7) services. Per the American Society of Addiction Medicine (ASAM) criteria this patient met Level 3.7 criteria for RTC services. Admission is appropriate when specifications are met in at least two of the six dimensions, at least one of which is from dimensions 1, 2, or 3. For dimension 1, the patient reported that his last drink was the day prior to admission. The patient was placed on five-day lorazepam protocol and a five-day buprenorphine taper. The patient required a withdrawal management protocol.  For dimension 2, the patient does not have any reported medical problems. The patient was medically stable at the time of this admission. The patient did not meet the criteria of interaction of the patients biomedical condition and continued alcohol use places the patient at significant risk of serious damage to physical health, or current biomedical condition required 24-hour nursing and medical monitoring or active treatment, but not the full resources of an acute care hospital. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 3, the patient reported that he was diagnosed with bipolar disorder that required two psychiatric hospitalizations years ago. The patient reported that he previously had two suicide attempts and he was suicidal for six months prior to treatment. The patient was noted to have significant insomnia and a decreased appetite. Given the patients history of bipolar diagnosis, prior suicide attempts, and recent suicidal ideation, he posed a risk of harm to himself or others if not contained in a 24-hour structured environment. The patients psychiatric condition was unstable and presented with symptoms that interfered with abstinence, recovery, and stability to such a degree that the patient needed a structured 24-hour medically monitored environment to address recovery efforts. For dimension 4, the patient was admitted voluntarily for treatment of his alcohol use disorder and opioid use disorder. The patient was also started on treatment for his bipolar disorder. The patient reported that has a history of two prior suicide attempts. The patient needed ongoing 24-hour psychiatric monitoring to assure follow through with the treatment regimen, and to deal with issues such as ambivalence about adherence to psychiatric medications and a recovery program. For dimension 5, the patient reported drinking one to two pints of liquor daily for six months as well as oxycodone daily for two years. The patient endorsed suicidal ideation for six months. The patient was unable to eat or sleep. The patient was previously treated in detoxification, but he was unable to maintain sobriety in the community. The patient was experiencing an acute psychiatric or substance use crisis, marked by intensification of symptoms of his addictive or mental disorder, which posed a serious risk of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient lives alone. The patient did not require continuous medical monitoring while addressing his substance use due to his current living situation being characterized by abuse, others living with the patient are not supportive of his recovery goals, or that the patient was unable to cope, for even limited periods of time, outside of 24-hour care. The records do not demonstrate that the patient required staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Based on these findings, the patient does not meet the requirements for this dimension.This patient meets criteria for ASAM Level 3.7 services as criteria are met in at least two of the six dimensions, including at least one dimension from dimensions 1, 2, or 3. Specifically, the patient meets the requirements for dimensions 3, 4, and 5. Moreover, the RTC subacute detoxification services were 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. Given these findings, the RTC subacute detoxification (ASAM Level 3.7) services were medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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.