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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided by The Lakes Treatment Center from 9/08/21 forward.At issue is whether RTC services provided by The Lakes Treatment Center from 9/8/21 forward were and/or are medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A) set forth below. 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.Per the American Society of Addiction Medicine (ASAM) criteria, this patient met and meets Level 3.5 criteria for RTC services provided by The Lakes Treatment Center from 9/8/21 forward. 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 withdrawal management for benzodiazepine withdrawal earlier in his treatment stay. The patients withdrawal needs could have been and could be safely managed in a Level 3.5 setting.For dimension 2, the patient has history of withdrawal seizures and overdoses requiring Narcan. The patients biomedical problems were and are stable.For dimension 3, the patient has been diagnosed with PTSD and MDD. He has been using fentanyl daily for most of the past 10 years. The patient has a history of multiple overdoses requiring Narcan. He continued to use after the life-threatening overdosage. He uses benzodiazepines along with fentanyl and has had several blackouts, including one the day before his admission. He also smuggled a substance that appeared to be black tar heroin into the facility. Based on these findings, the patient met and meets the requirements for this dimension.For dimension 4, the patient was admitted voluntarily for treatment. The patient has been using heroin and fentanyl for the past ten years and has significant relationship, medical, and legal problems. He has had serious consequences from his addiction including seizures and difficulty finding and maintaining work due to his drug usage and criminal record. The patient has repeatedly put himself into high risk situations and engaged in antisocial behavior as evidenced by his extensive legal history. The patient was noted to have impaired insight into his condition and was lacking in coping skills to manage relapse triggers. Based on these findings, the patient met and meets the requirements for this dimension.For dimension 5, this patient has had ongoing cravings and urges to use opiates. The patient has been using fentanyl combined with benzodiazepines to the point of blackouts and had an overdose requiring Narcan in July 2021. Based on these findings, the patient met and meets the requirements for this dimension.For dimension 6, the patient has been living with mother who is noted to be an alcoholic. His social network consists of other drug users. He does not have a sober support network. Based on these findings, the patient met and meets the requirements for this dimension.The ASAM criteria requires adult patients to meet all six dimensions to support residential treatment center services. This patient met and meets all the dimensions for Level 3.5 residential treatment center criteria. Moreover, the services were and are in accordance with the generally accepted standards of mental health and substance use disorder care. The services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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. Given these findings, RTC services provided by The Lakes Treatment Center from 9/8/21 forward 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 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.