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. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 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 patient was admitted to RTC and managed for withdrawal with a five-day Librium taper. He continued to have withdrawal symptoms including agitation, anxiety, and cravings. The patients withdrawal needs can be met in Level 3.1 setting.For dimension 2, the patient does not have any medical problems. The patients biomedical problems are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has a history of childhood trauma. The patient reports difficulty with anger and intermittent passive suicidality. The provider reported that the patient has participated in groups. The patients mental status has been assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition is stable and he is assessed as having minimal problems in this area as evidenced by both of the following: (1) the patients depression may be related to substance use problems or to a stable co-occurring emotional condition with imminent likelihood of relapse with dangerous consequences outside of a structured environment; and (2) the patient is assessed as not posing a risk to self or others. For dimension 4, the patient admitted himself for treatment since he was unsuccessful in stopping his polysubstance use on his own and had developed depression, anger problems, and passive intermittent suicidality. He has expressed a desire to become abstinent and he has been able to identify negative consequences of his substance usage including mental health problems, occupational problems, and relationship problems. The patient acknowledges the existence of a substance use problem. He recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been using multiple substances including alcohol, Xanax, Vicodin, cocaine, and methamphetamine on a near daily basis for the past five years. He has no history of abstinence despite multiple attempt to quit using on his own. He reports suicidality due to ongoing substance usage. He has been unaware of relapse triggers and he admits that he does not have adequate coping skills for managing his urges to use. The patient demonstrates limited coping skills to address relapse triggers and urges. He is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient lives with his parents and his father uses alcohol. The patient reported that he had no knowledge of relapse triggers or any skills to manage his cravings and triggers. The patient is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. The patient has been living in an environment that is characterized by the risk of repetition of physical or emotional abuse, or substance use so endemic that the patient is assessed as being unable to maintain recovery at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC level of care services 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.