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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for RTC services provided at The Lakes Treatment Center. 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. For dimension 1, the patient was managed with a chlordiazepoxide taper upon admission. The patients withdrawal needs were safely managed in level 3.5 setting. For dimension 2, the patient had a history of epilepsy. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patients diagnoses included a psychotic disorder, generalized anxiety disorder, and agoraphobia. The record noted delusions about recent events, problems with reality testing, and paranoia with delusions about items being put under his skin. He was actively psychotic and had auditory hallucinations. He continued to be distressed over his psychotic symptoms. He had been hospitalized briefly prior to admission to the RTC following an overdose. The patients mental status was stable enough to permit participation. Despite his best efforts, the patient was unable to control his use of alcohol and other drugs and was in imminent danger of relapse with attendant likelihood of harm to self.  For dimension 4, the patient was unemployed. His psychosis was exacerbated by his ongoing amphetamine use. He had been asked to leave his SLE home. He reported using methamphetamines singe age 11. The records noted that the patient had difficulty maintaining motivation and focus while in group sessions. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because of limited insight due to the intensity and chronicity of the addictive disorder. For dimension 5, patient had a history of prior RTC admissions. The records noted continued psychosis and anxiety, and that the patient had little insight into his condition and the role that substances played in his symptoms. He had ongoing problems with impulse control. Despite recent, active, participation in treatment at a less intensive level of care, the patient continued to experience psychiatric or addiction symptoms such as drug craving and was at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient reported that he was basically homeless as his family did not want him to return home until he had been clean for one year. He had been selling drugs and asked to leave his last SLE home. He was unemployed. The patient was unable to cope, for even limited periods of time, outside of 24-hour care such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, the RTC services provided at The Lakes Treatment Center were medically necessary for the 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 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.