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

The patient has requested reimbursement for residential treatment center (RTC) substance use disorder services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 criteria for RTC substance use disorder 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 did not have withdrawal symptoms. The patient had no signs or symptoms of withdrawal. For dimension 2, the patient has a history of exercise-induced asthma and she was medically stable. The patients biomedical problems, if any, were stable and did not require medical or nurse monitoring. For dimension 3, the patient complained of anxiety and depression. She was also noted to be impulsive and manipulative. She reportedly spent most of 2018 in and out of short-term residential settings and was using substances while at a sober living facility since October 2018. The patients mental status was assessed as sufficiently stable to allow the patient to participate in therapeutic interventions provided at this level of care and to benefit from treatment. The patients symptoms and functional limitations, when considered in the context of her home environment, were sufficiently severe that she was assessed as not likely to maintain abstinence if treatment is provided in a nonresidential setting. For dimension 4, the patient was assessed as being in the contemplative stage of change. The provider noted that the patient demonstrated significant impulse dyscontrol as evidenced by her using fentanyl and ketamine in her sober living facility. The patient required 24-hour structured milieu to promote treatment progress and recovery, because motivating interventions have failed in the past and such interventions were assessed as not likely to succeed in an outpatient setting. For dimension 5, the patient has been in multiple short-term treatment programs and relapsed after discharge. She was using fentanyl and ketamine in her sober living facility. The providers describe the patient as impulsive and manipulative. The patient demonstrated limited coping skills to address relapse triggers and urges. She was in imminent danger of relapse with dangerous emotional and behavioral consequences, and needed 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient was most recently living in a sober living facility, but she was previously living with her mother and siblings. Her social network consists of substance users. The patient was able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program to pursue community activities. The patient has high-risk social contacts that jeopardized her recovery, and led recovery goals to be assessed as unachievable outside of a 24-hour supportive setting. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC substance use disorder services were medically necessary for treatment of this patient.