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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center (RTC) level of care services.The submitted documentation supports that Residential Treatment Center (RTC) level of care services were, and are, medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the patient demonstrates symptoms consistent with subacute/protracted withdrawal, as evidenced by elevated Clinical Opiate Withdrawal Scale (COWS) scores of 12-24, agitation, anxiety, tremors and chills. The patient also experienced paranoia and depression. These symptoms place the patient at an elevated risk of relapse. For dimension 2, biomedical conditions and complications, the patient had a recent hospitalization for osteomyelitis that was directly related to intravenous drug abuse and poor self-care. The patient also required an urgent care evaluation for abdominal pain and constipation and continued to have genitourinary issues such as urinary retention. For dimension 3, emotional, behavioral, or cognitive conditions and complications, records reflect that the patient is clearly unable to control his substance use without 24 hour support, as provided within a 24 hour residential treatment center. The patients inability to control his impulses includes risky sexual behavior and self-sabotaging behavior that have led to significant anxiety and acting out. Prior to admission he had been discharged against medical advice secondary to severe agitation and anxiety and relapsed within hours of leaving the program. For dimension 4, readiness to change, the patient showed opposition to addressing his substance use disorder problem, as evidenced by drug seeking and manipulation while on the medical unit. He has demonstrated an inability to control his impulses and a need for a 24 hour program milieu that is highly structured to prevent him from acting on his impulses and relapsing. For dimension 5, relapse, continued use, or continued problem potential, the patient continues to have significant cravings and is at imminent danger of relapse if discharged. He has demonstrated a repeated inability to remain sober without a structured 24 hour residential treatment center level of care and has experienced potentially life threatening sequelae from his substance use disorder and subsequent poor self-care. For dimension 6, recovery environment, records indicate that the patient is unable to stay away from old friends whom he has identified as bad influences and has been quickly homeless and quickly relapses after discharge. The patient is also lacking family and social supports that would permit treatment at a lower level of care. The submitted documentation thereby reflects that the patient requires a safe and stable living environment in order to develop his recovery skills, thus qualifying for ASAM Level 3.5 treatment at least, which is similar to what the patient has received at the facility. Treatment may be required at Level 3.5 if an individual is not progressing and faces imminent danger if not in a supportive 24-hour treatment setting. Given the severity of the patients illness, residential treatment center services were, and are, clinically appropriate for the patient's illness. Therefore, the requested Residential Treatment Center level of care was, and is, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat 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.