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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for dual diagnosis 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 was managed for alcohol withdrawal with a Librium taper when he was initially admitted for treatment. The patients withdrawal needs could have been met in a Level 3.5 setting.For dimension 2, the patient is legally blind in one eye, but he does not have any other 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 been diagnosed with schizoaffective disorder, but he had primarily problems with post-traumatic stress disorder (PTSD) symptoms and depression with chronic passive suicidal ideation and intermittent periods of active suicidal ideation. He demonstrated ongoing symptoms of PTSD including guilt, shame, hypervigilance, paranoid ideation, and anger dyscontrol. He was able to 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 were sufficiently severe that the patient was not likely to maintain abstinence if treatment was provided in a non-residential setting. The functional deficits were of a pervasive nature and included residual psychiatric symptoms. For dimension 4, the patient was admitted voluntarily because the patient was committing crimes with a plan to get himself shot by the police. He was using a large amount of cocaine and getting into altercations. The patient was unemployed and homeless due to his substance abuse problems. He was pessimistic about his ability to have a life without use of substances. Because of the intensity and chronicity of the addictive disorder, he had limited insight and little awareness of the need for continuing care and thus had limited readiness to change. For dimension 5, the patient has experienced difficulty with maintaining sobriety outside of a controlled or structured setting. He was in the RTC for 35 days in early 2020 and was able to stay clean for 55 days then relapsed after a breakup rendered him homeless. He continued to express pessimism and hopelessness regarding his emotional state and his ability to maintain abstinence given his previous lifestyle. The patients psychiatric condition was stabilizing. However, despite his best efforts, the patient was unable to control his use of substances and antisocial behaviors with attendant probability of harm to self and others. The patient had limited ability to interrupt the relapse process or continued use. His 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 was homeless and affiliated with a gang. He received support from his father who has an alcohol use disorder. His peers consist of drug users. He was pessimistic about his ability to remain abstinent in his former environment given his past lifestyle. The patient was unable to cope, for even limited periods of time, outside of 24-hour care. He needed staff monitoring to learn to cope with dimension 6 problems before being transferred to a less intensive setting. Given these findings, this patient met the six ASAM dimensions for dual diagnosis RTC services. Therefore, the dual diagnosis 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 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.