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 (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria this patient met Level 3.5 criteria for RTC services. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. 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 for sedative-hypnotic withdrawal earlier in his treatment stay. Thus, the patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient does not have medical problems. 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 been diagnosed with anxiety disorder and depressive disorder. The records document that the patient has been misusing Xanax on a daily basis for years and he has a history of withdrawal seizure. The patient has experienced significant legal consequences related to his substance use disorder. The provider noted that the patient continues to be impulsive regarding how to proceed with 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. In addition, the patient has demonstrated repeated inability to control his impulses to use alcohol and/or other drugs and/or to engage in antisocial behavior and is in imminent danger of relapse with attendant likelihood of harm to self or others. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted voluntarily for treatment after he was unable to stop using methamphetamine and Xanax on his own. The patient endorsed use of 1 gram of methamphetamine daily and Xanax daily for several years. The records suggest that the patient is still ambivalent about his need for treatment and aftercare. The patient was indecisive about how to proceed with continuing care arrangements. Because of the intensity and chronicity of the addictive disorder, he has limited insight and little awareness of the need for continuing care or the existence of his substance use and need for treatment, and thus has limited readiness to change. For dimension 5, the patient has undergone three prior attempts at treatment. His longest period of sobriety has been 30 days. The patients substance usage has resulted in legal problems. The patient does not fully recognize relapse triggers as evidenced by his request to return home where there is ongoing substance usage. The patient demonstrated minimal ability to implement adaptive coping skills in order to avoid relapse. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. His continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient has been living with his mother and stepfather. There is active substance usage within the home. He is a laborer and notes that his coworkers also use substances. He has consistently relapsed when in his home environment. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Based on these findings, the patient meets the six ASAM dimensions to support RTC services (ASAM 3.5). Moreover, the RTC services (ASAM 3.5) were and 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 not primarily for the convenience of the patient or provider. All told, the RTC services (ASAM 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.