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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for clinically managed high-intensity residential 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. The records document that the patient was in withdrawal and she required a prolonged taper of Valium. She had an adverse reaction to Librium, which is a standard a first-line option for detoxification. A prolonged benzodiazepine taper was required due to her withdrawal symptoms including rebound, worsening anxiety, and insomnia. Her continued substance use placed her health at serious risk. The records suggest that her continued use of high dose benzodiazepines and stimulants likely contributed to her significant decompensation that rendered her unable to care for herself. She demonstrated limited decision-making capacity to participate in the milieu, despite poor insight and judgment. She was unable to control her substance use without 24-hour RTC services. She was noted to frequently digress into a psychotic and suicidal state in which she refused to bathe, eat, or sleep. She reported that she was distressed since she was under the control of a clairvoyant who placed a hex on her. The patients benzodiazepine taper was complicated given her lengthy history of prolonged high dose benzodiazepine use. Her significant functional deficits required close staff intervention given her reluctance to bathe, persecutory delusions, inability to care for herself, and suicidal ideation. At times the patient refused medications, further supporting that she had limited insight and judgment. Her coping and functioning were significantly impaired as evidenced by impaired reality testing, refusing to bathe or eat, and picking at herself due to persecutory delusions and paranoia. The patient was at imminent danger of relapse given her suicidal ideation and poor functioning. During her stay at the RTC, the patient became suicidal after a confrontation with her mother. The patient was noted to have an unstable living environment prior to admission and she had deteriorated to the point where she could no longer care for herself. Based on these findings, the 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 is board certified in psychiatry with expertise 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.