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

Findings:  The physician reviewer found that The patient has requested reimbursement for (1) residential treatment center (RTC)  services (ASAM 3.7) and (2) RTC services (ASAM 3.5). Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.7 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. Admission is appropriate when specifications are met in at least two of the six dimensions, at least one of which is dimensions 1, 2, or 3.The patient met the criteria for Level 3.7 services, as specifications were met in at least two of the six dimensions, at least one of which was dimensions 1, 2, or 3. Specifically, the patient met criteria in dimensions 1, 3, 4, 5, and 6. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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. Accordingly, (1) RTC services (ASAM 3.7) were medically necessary for treatment of this patient.At issue is whether (2) RTC services (ASAM 3.5) were medically necessary to treat the patients mental health or substance use disorder 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 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. The patient also met the six ASAM criteria for RTC services for a different timeframe. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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. Accordingly, (2) RTC services (ASAM 3.5) 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.