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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services (ASAM level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet 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 was treated for opioid withdrawal earlier in his course of treatment. The patients withdrawal needs could have been safely managed in a Level 3.5 setting.For dimension 2, the patient has human immunodeficiency virus (HIV), sequelae of prostate resection, chronic back pain, hypertension, and hyperlipidemia. The patients biomedical problems were stable and did not require medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient was noted to be depressed due to his physical health problems following prostate resection. The patient denied suicidal and homicidal ideation. He participated 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. However, the patient does not meet any of the other qualifying criteria including unable to control his use of alcohol and drugs with attendant probability of imminent danger, demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, demonstrates antisocial behavior patterns, has significant functional deficits which are likely to respond to staff interventions, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Based on these findings, the patient did not meet the requirements for this dimension. For dimension 4, the patient admitted himself for treatment voluntarily as he was concerned about the effect opioids were having on his relationship and occupational functioning. He actively participated in treatment and was developing insight into his addiction. The patient did not meet any of the criteria for this dimension such as limited insight and little awareness of the need for continuing care, demonstrates passive or active opposition to addressing the severity of his addiction problem, required structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care, perspective impairs his ability to make behavior changes without repeated, structured motivational interventions, or expressed little to no interest in changing. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 5, the patient was using fentanyl three to four times weekly, and this was his first attempt at treatment for opioid use disorder. He recognized the need for treatment and continuing care. The patient denied suicidal and homicidal ideation. The patient was on medications for cravings. The patient did not meet the requirements for this dimension including lacked insight into benefits of continuing care, unable to control use of alcohol or drugs with attendant probability of harm to self or others, experiencing craving with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, despite recent active participation in treatment at a less intensive level of care, the patient continues to use alcohol or drugs, or demonstrates a lifetime history of repeated incarceration. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 6, the patient is married and lives with his spouse, who uses cannabis and drinks alcohol. This issue was discussed earlier in his treatment stay and attempts were made to involve his spouse in his treatment. The patient is employed and was on medical leave. The patients social network involved living with an individual who is a regular user or dealer of other drugs. Given these findings, the patient did not meet ASAM level 3.5 RTC criteria for dimensions 3, 4, and 5. ASAM requires adult patients to meet all six dimensions to support RTC services. For these reasons, the RTC services (ASAM level 3.5) were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.