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) (ASAM 3.5) level of care. Findings:  The physician reviewer found that 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 patients methamphetamine withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had GERD and pain in his ankle from injecting methamphetamines. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient did not appear to be an imminent danger to self or others. The patients mental status (including emotional stability and cognitive functioning) 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. For dimension 4, the patient was in the contemplative phase, and had insight into the severity of his drug use. He was willing and accepting of treatment. The patient was able to understand the relationship between his substance use, addiction, mental health, or life problems. The records did not support that the patient required 24-hour programmatic milieu to sustain motivation. This criterion was not met.For dimension 5, the records do not support that the patients continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The patients drug seeking behaviors did not appear to pose an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support.  Moreover, the records do not support an imminent danger of relapse. This criterion was not met.For dimension 6, the patient was renting a room through Airbnb and received a monthly income.  The records did not indicate that the patient was living in an environment where drug use was so endemic that that the patient was assessed as being unable to achieve or maintain recovery at a less intensive level of care. The patient did not appear to be in an imminent danger of continued drug use based on his recovery environment. This criterion was not met.Given these findings, the patient did not meet the six ASAM criteria for RTC services. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. Accordingly, RTC (ASAM 3.5) level of care provided was 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 sub-specialty certification in addiction 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.