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) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 criteria for RTC. 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 after he completed over two months of abstinence while at a detoxification facility. The patient had no signs or symptoms of withdrawal. The patients withdrawal needs could have been met in Level 3.1 setting. For dimension 2, the patient had history of benzodiazepine withdrawal seizures, which required treatment with Keppra. The patients biomedical problems were stable and did not require medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has a history of childhood trauma due to abuse. He has reported significant depression since adolescence. He indicated that he started using substances and engaging in self-injurious behaviors at age 12. He has experienced difficulty tolerating emotions and he expressed thoughts of self-harm and suicidal ideation. He participated in groups. The patients mental status was assessed as stable to permit participation in the therapeutic interventions available at this level of care and to benefit from treatment. The patients symptoms and functional limitations, when considered in the context of his home environment, were sufficiently severe that he was assessed as not likely to maintain mental stability and abstinence if treatment was provided in a nonresidential setting. Functional limitations may include residual psychiatric symptoms and chronic addictive disorder. For dimension 4, the patient voluntarily admitted himself for treatment to another facility for detoxification and then he was transferred to the RTC due to self-injurious behaviors. He expressed a desire to become abstinent and he was able to identify negative consequences of his substance usage. The patient acknowledged the existence of a substance use problem. He recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient endorsed use of multiple substances including heroin, cannabis, Xanax, and cocaine on a daily basis for several years. He has no history of abstinence or treatment prior to the detoxification facility and subsequent RTC admission. He has reportedly had 10 overdoses in the past year. He has not developed coping skills for managing urges to use or his negative emotional states. The patient demonstrated limited coping skills to address relapse triggers and urges. He was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient lives with his brother, with whom he has a strained relationship, and his mother. This provider described the patient as lacking coping skills to manage cravings and triggers. He also lacks coping skills for managing frustration, sadness, or anxiety without resorting to self-injurious behaviors. The patient was 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 was living in an environment that was characterized by the risk of repetition of abuse, or substance use so endemic that the patient was assessed as being unable to maintain recovery at a less intensive level of care. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC services were medically necessary for treatment of this patientFinal 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.