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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for subacute substance abuse rehabilitation services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 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 reported withdrawal symptoms of insomnia, restlessness, and agitation. The patient has completed a phenobarbital taper and suboxone induction. The patients withdrawal needs can be safely managed in Level 3.1 setting. For dimension 2, the patient has an abscess of the left forearm due to intravenous (IV) drug use. The patients biomedical problems are stable and do not require medical or nurse monitoring. For dimension 3, the patient has been diagnosed with depression, borderline personality disorder, and bulimia. The patient is also transgender with depression and social anxiety, which has been managed by using substances. The patient reportedly recently attempted suicide due to drug use and hallucinations. The provider noted that the patient has been actively participating in groups. The patients mental status is stable to permit participation. The patients symptoms and functional limitations, when considered in the context of home environment are sufficiently severe that the patient has been assessed as not likely to maintain abstinence if treatment is provided in a nonresidential setting. For dimension 4, the patient voluntarily admitted themself due to worsening consequences of uncontrolled drug usage with a repeat DUI and suspension of license. The patient is also now homeless. The patient has been motivated to complete the program. The patient acknowledges the existence of a substance use problem and is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has continued to use IV heroin, methamphetamine, and Xanax after three prior attempts at treatment. He uses substances in a maladaptive manner in order to cope with the stressors in his life. The patient understands addiction and mental disorder but is at risk of relapse in a less structured level of care due to inability to consistently address either or both. For dimension 6, the patient is homeless, unemployed and socially isolated. The patient is on probation and his drivers license was suspended due to repeated charges of driving under the influence. The patient is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Moreover, continued exposure to the patients living environment makes recovery unlikely and the patient has insufficient skills to maintain adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient meets the six ASAM dimensions to support RTC services. Therefore, the subacute substance abuse rehabilitation services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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 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.