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 demonstrated symptoms of withdrawal including sweating, tremor, restlessness, and anxiety. The patient experienced intermittent tachycardia with an elevated heartrate. The patients symptoms of withdrawal could safely be managed at a Level 3.5 RTC setting. For dimension 2, the patients biomedical conditions were not severe enough to warrant inpatient treatment but was sufficient to distract from recovery efforts. Her biomedical conditions included continued protracted withdrawal and bulimia. The patients medications included clonidine, Ativan and Suboxone. The patient requested to discontinue buprenorphine, which required a taper at the RTC level of care for appropriate medical support and monitoring. The patient received treatment with Ativan. The patient was in need of biomedical enhanced services for biomedical conditions that required a degree of staff attention. She required assistance for adherence with medication administration that is not available in other Level 3.5 programs. For dimension 3, the patients mental status was sufficient in order to participate in the program. The patient demonstrated inability to control her impulses to use potentially lethal amounts of intravenous heroin, in combination with benzodiazepines and methamphetamine, and is at great risk of relapse. She has engaged in antisocial behaviors including criminal activity related to her drug use. The resulting level of dysfunction was so severe that it precluded the patients participation in a less structured and less intensive level of care than RTC. For dimension 4, the patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care and such interventions were assessed as not likely to success at a less intensive level of care. The patient was previously treated with 12-step and other outpatient programs, which did not facilitate her recovery. She has also demonstrated relapse of her bulimia during periods of sobriety and there is mention of instances of purging while in the RTC. The patient voiced that being sober exacerbated her eating disordered behaviors. For dimension 5, the patient was experiencing anxiety and cravings to use substances. She demonstrated an inability to postpone immediate gratification and other drug seeking behaviors. She was unable to stop using substances in an outpatient setting. The patient has a history of an overdose, withdrawal related seizure, and engagement in criminal activities to support her substance use disorder. The introduction of psychopharmacologic support was indicated to decrease addictive symptoms, such as cravings, that would enable the patient to delay immediate gratification and reinforce positive recovery behaviors. The patient required Ativan and clonidine after she stopped taking buprenorphine, and she required several other medication changes during her RTC stay to target problematic symptoms and cravings, such as Haldol to address hallucinations and delirium. This highlights the patients need for the monitoring provided at the RTC level of care in response to cravings and other symptoms documented such as anxiety, depression, poor concentration, flashbacks, and hopelessness. For dimension 6, the living, occupational and social environments were not conducive to the patients recovery or good mental health functioning. She had no steady, stable, living environment that would support her recovery outside the 24-hour treatment facility. After discharge, the patient was to spend one night at her mothers house and then discharge to a sober living facility. It was imperative that the patient receive the support and structure of the Level 3.5 co-occurring enhanced program to achieve stabilization and prevent further deterioration. Given these findings, this patient met the six ASAM dimensions for Level 3.5 services during the period under review. 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.