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) level of care services (ASAM 3.5). Findings:  The physician reviewer found that American Society of Addiction Medicine (ASAM) criteria, this patient met 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 patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had no acute medical problems. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has a history of bipolar disorder and benzodiazepine overdoses. The patients mental status including emotional stability and cognitive functioning was 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, despite his best efforts, the patient demonstrated that he was unable to control his substance use and antisocial behaviors including incarcerations and selling drugs, with attendant probability likelihood of harm to self, others, or property. The resulting level of dysfunction was so severe that it precluded the patients participation in treatment in the absence of a the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was in the pre-contemplative phase regarding his alprazolam use, describing his use of benzodiazepines as not a problem. The patient was not able to understand the relationship between his substance use, addiction, mental health, or life problems. The patient was isolative in groups, minimized use, and blamed other for his substance use. The records document that the patients perspective impaired his ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable him to develop insight into the role he plays in his substance use and mental condition and empower him to make behavioral changes which can only be delivered in a 24-hour milieu. For dimension 5, the records support that the patients continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The patient previously left against medical advice after three days of treatment. Moreover, it is noted that the patient has blacked out on benzodiazepines while driving or in public places. Despite recent, active participation in treatment at a less intensive level of care, the patient continued to use alcohol or other drugs with imminent serious consequences and was at high-risk of continued substance use or mental deterioration in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient was surrounded by family members who actively use drugs and the patient engaged in illegal activities to support his substance use disorders. The patient did appear to be in an imminent danger of continued drug use based on his recovery environment. The records support that the patient was living in an environment that was characterized by substance use so endemic that that the patient was assessed as being unable to achieve or maintain recovery at a less intensive level of care. The ASAM guidelines require adult patients to meet all six dimensions to support Level 3.5 RTC services. This patient met Level 3.5 RTC criteria for dimensions 1-6. In addition, the RTC 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 services (ASAM Level 3.5) 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.