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 2.5 criteria for partial hospitalization program (PHP) services. Per ASAM problems in dimensions 1, 2, and 3 are not medically necessary for admission to a level 2.5 program. This patient met the criteria for dimensions 3, 4, 5 and 6. 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 3, the patient had significant distress from OCD symptoms, which was exacerbated by the slow taper off Klonopin. He was lowered to 0.25 mg twice daily after being on 4 mg daily on a longstanding basis. He was also recovering from months of abusing high dosage Adderall, which was tapered rapidly. The patient has a history of moderate psychiatric decompensation on discontinuation of the addictive drug. Such decompensation was observable. For dimension 4, the patient was noted to be in the contemplative stage of change. He previously relapsed after recent intensive outpatient program (IOP) level of care that was conducted virtually. He was previously unable to sustain motivation to participate in virtual program at home. The patient had difficulty tolerating the taper off Klonopin due to increased level of anxiety and focus on distressing OCD symptoms. The patient also had to be talked out of leaving against medical advice. The patient required structured therapy and a programmatic milieu to promote treatment progress and recovery because motivational interventions at another level of care have failed. Such interventions were not likely to succeed in a Level 2.1 program. For dimension 5, the patient had previous virtual IOP treatment in 2020, but he relapsed due to boredom and lack of motivation. He experienced significant difficulty tolerating the slow taper of Klonopin due to anxiety and worsening of his OCD symptoms. He was in such distress that he requested to leave against medical advice. There was a high likelihood that the patient would have continued to use or relapsed to use of substances without close outpatient monitoring and structured therapeutic services, as indicated by his lack of awareness of relapse triggers or ambivalence toward treatment. The patient unsuccessfully attempted treatment at a less intensive level of care. For dimension 6, the patient lives alone and is unemployed. He did not have any sober social network. He was socially isolated as his family lives out of town. He previously was unsuccessful with virtual IOP treatment. Continued exposure to the patients current living environment would have rendered recovery unlikely. The patient lacked the skills necessary to maintain adequate level of functioning without the services of a Level 2.5 program. Per ASAM problems in dimensions 1, 2, and 3 are not medically necessary for admission to a level 2.5 program. This patient met the criteria for dimensions 3, 4, 5 and 6. Given this support, the PHP 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.