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 3.5 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 underwent a slow taper of clonazepam and she experienced substantial difficulty and complaints of anxiety, panic, insomnia, poor concentration, and irritability. The patients withdrawal needs could have been met in Level 3.5 setting.For dimension 2, the patient has medical problems of celiac disease. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has been treated for obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and panic attacks with Klonopin for the past five years. She has become nonfunctional due to this Klonopin dosage and she has been unable to work, maintain friendships, or attend to her activities of daily living. She was unable to tolerate a taper of Klonopin in the community even with small changes in dosage. She was not attending to her hygiene while in the facility. The patients mental status was assessed as sufficient to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has significant functional deficits, which are likely to respond to staff interventions. These symptoms and deficits, when considered in the context of her home environment, are sufficiently severe that the patient is not likely to maintain stability or abstinence if treatment is provided in a non-residential setting. The deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus; they did not require medical monitoring or management. They may include residual psychiatric symptoms and chronic addictive disorder. For dimension 4, the patient was admitted voluntarily at the urging of her psychiatrist and parents due to failure at a lower level of care. She has been taking 5 mg of clonazepam daily for the past 5 years and has been unable to function due to sedation. She has been unable to tolerate minute reductions in her Klonopin dosage. She demonstrated poor insight into her clonazepam use and expressed that she did not need to be in the treatment facility. She felt that she did not have a substance use disorder. Because of the intensity and chronicity of the addictive disorder or the patients mental health problems, she had limited insight and little awareness of the need for continuing care or the existence of her substance use and mental health problem and need for treatment, and thus had limited readiness to change. For dimension 5, the patient has been taking increasing dosages of Klonopin daily since age 22. Her parents report that she has been in a partial hospitalization program (PHP), intensive outpatient program (IOP), and cognitive behavioral therapy (CBT) for her severe anxiety. She has most recently been working with outpatient provider to perform a slow taper, but she has been unable to tolerate the anxiety and physical sensations of lower dosages. She has an extremely low ability to tolerate any distress and was often noted to be crying with labile affect. She often endorsed feeling hopeless. Despite recent, active participation in treatment at a less intensive level of care, the patient continued to use drugs or to deteriorate psychiatrically, with imminent serious consequences, and was at high risk of continued substance use or mental deterioration in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient has been living with her parents and siblings. She has no outside friendships or relationships. She feels wary and suspicious of others such that she will not interact with them. She has been unemployed for the past five years due to her mental health issues and clonazepam usage. She spends all of her time in her bedroom at home sleeping and was unable to comply with outpatient taper of clonazepam. The patient was unable to cope, for even limited periods of time, outside of 24-hour care. She needed staff monitoring to learn to cope with Dimension 6 problems before she could be safely transferred to a less intensive setting. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC level of care services were medically necessary for treatment of this patient.Final 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.