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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center level of care.At issue is whether Residential Treatment Center (RTC) services were, and are, medically necessary to treat the patients mental health or substance use disorder, as defined in Health and Safety Code section 1374.72(a)(3)(A).California Health and Safety Code section 1374.72(a)(3)(A) states that Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following:(i)In accordance with the generally accepted standards of mental health and substance use disorder care.(ii)Clinically appropriate in terms of type, frequency, extent, site, and duration.(iii)Not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.American Society of Addiction Medicine (ASAM) criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient underwent withdrawal management for opioid withdrawal earlier in her treatment stay and was on Suboxone maintenance. The patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. The patient is in her third trimester of pregnancy and needs to have multiple teeth extracted. The patients biomedical problems, if any, were stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient has been diagnosed with PTSD and depression. She has been using methamphetamine and fentanyl daily for 3 to 5 years, except for when she has been in a treatment facility. She has used all through her pregnancy, which is potentially dangerous to the fetus. She continued to have cravings to use both methamphetamine and fentanyl despite being on Suboxone. Notes indicate that she brought drug paraphernalia and pills into the treatment facility. The patients mental status permitted participation. The patient demonstrated a repeated inability to control her impulses to use alcohol and other drugs 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 - Readiness to Change. The patient was admitted voluntarily for treatment. She has been using fentanyl and methamphetamine her entire pregnancy and was arrested for drug sales recently. She has been using fentanyl and methamphetamine daily for 3 to 5 years. She was noted to minimize her drug usage and expressed that she did not need to be on Suboxone maintenance once she was out of the facility. Because of the intensity and chronicity of the patients addictive disorder, she has limited insight and little awareness of her need for continuing care or the existence of her substance use problem and need for treatment and thus has limited readiness to change.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient was started on Suboxone during this treatment stay but was continuing to have ongoing post-acute withdrawal syndrome (PAWS) with cravings, irritability, and mood swings. The patient is therefore experiencing addiction symptoms such as drug craving. This situation poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors.For dimension 6 - Recovery Environment. The patient has not been able to cope without using substances outside of a 1-week period after a residential treatment center admission. The patient has been unable to work due to her addiction. All of her family members are active addicts. She is homeless as her last place of residence was with a drug-dealer and her sister who also uses fentanyl. She has been in a relapse for months using drugs in a home environment. She does not have any firm sober supports in the community, as the father of her child is also in treatment for the same addictions. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. She needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting.Using the ASAM level 3.5 criteria worksheet, the patient meets all six criteria for medical necessity and therefore qualifies for ASAM Level 3.5 treatment. The patients scores under the six ASAM criteria take into account the specific needs of the patient for the purpose of treating their illness and its symptoms. The ASAM criteria for determining the appropriate level of care is consistent with generally accepted standards of mental health, and it provides determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The ASAM criteria are also free from consideration of the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the Residential Treatment Center services (equivalent to ASAM 3.5) were, and are, medically necessary to treat the patients mental health or substance use disorder, as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients mental health or substance use disorder, as defined in Health and Safety Code section 1374.72(a)(3)(A). Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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.