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 did not require withdrawal management for cannabis use disorder and hallucinogen use disorder. The patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient does not have any reported medical problems. 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 diagnoses of autism, bipolar disorder, and delusional disorder. He reportedly required at least three psychiatric admissions since February 2020 for a suicide attempt, aggressiveness necessitating a 5250 hold, and suicidal ideation with plan. He voiced that his entire life revolved around his drug usage and dealing, and that life without drugs was boring. He has been using cannabis regularly since age 13 and LSD since age 17 and at one point was using LSD daily. He did participate in groups. The patients mental status was assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient had significant functional deficits, which were likely to respond to staff interventions. These symptoms and deficits, when considered in the context of his home environment, were sufficiently severe that the patient was not likely to maintain abstinence if treatment was not provided in a non-residential setting. The functional deficits were of a pervasive nature and included residual psychiatric symptoms and chronic addictive disorder. For dimension 4, the patient was admitted to RTC voluntarily due to feeling depressed and dependent on drugs. In addition, the patients family reportedly would not let him return to live with them until he sought treatment. The patient was planned to return to live with his father, who uses cannabis regularly and enables the patients substance usage. The patient has been using cannabis heavily on a daily basis since age 13 and using LSD five tablets every two weeks to daily since age 17. He discussed being a drug dealer and his plans to continue using substances after discharge. The patient glorified drug use and disparaged recovery while in groups. Because of the intensity and chronicity of the addictive disorder or the patients mental health problems, he had limited insight and little awareness of the need for continuing care or the existence of his substance use problem and need for treatment, and thus had limited readiness to change. For dimension 5, the patient endorsed using cannabis heavily since age 13 and using LSD from every two weeks to daily since age 17. The patient has been in and out of treatment since age 15 and has undergone at least 13 prior treatment episodes. At times during his stay, he was open about returning to using drugs and glorified drug use during groups. He admitted that his entire life revolved around getting high and he did not have defined relapse triggers. He also voiced that recovery was boring. This patient has required hospitalization for 10 days after an aggressive episode while on LSD and an admission for a suicide attempt. The patient endorsed suicidal ideation with plan necessitating a psychiatric hospitalization during his RTC admission. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment. His continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient is single, unemployed, and homeless. His parents indicated that the patient needed to seek treatment in order to live with them. His father uses cannabis daily and he enables the patients substance use disorder by sharing his supply with the patient. The patient voiced that his entire life revolves around getting high. The patients  social network involves living with an individual who is a regular user, and the patients living environment was so highly invested in drug usage that his recovery goals were assessed as unachievable 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 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.