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 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 last use of alcohol and cannabis was in November 2019 as he was admitted to an acute psychiatric hospital for the month prior to the RTC admission under review. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient did not have any active medical problems. The patient has a history of an ACL tear in 2017. Based on the clinical findings, the patient did not require any 24-hour medical or nurse monitoring. For dimension 3, the patient has a long history of severe anxiety, both generalized and social. He reported that he had treated his anxiety with alcohol and cannabis. He then developed a severe manic episode with psychotic features that required a psychiatric hospitalization. The providers impression was that the episode was cannabis-induced. He was discharged from there to the RTC. In the RTC, the provider frequently noted that the patient was extremely anxious and he was titrated up on Neurontin. The patients mental status was sufficiently stable to permit participation in the therapeutic interventions. The patient demonstrated repeated inability to control his impulses to use alcohol and cannabis. He was in imminent danger of relapse with attendant likelihood of harm to himself. The resulting dysfunction was of such severity that it precluded participation in treatment in the absence of the 24-hour support and structure of a level 3.5 program. For dimension 4, the patient was assessed as having poor insight and awareness of his continued need for treatment. He was previously involuntarily committed to a psychiatric hospital. The patient reported that he was at the RTC due to his parents insistence. He has experienced legal and educations issues due to his substance use disorder. Thus, despite experiencing serious consequences or effects of the addictive disorder, the patient has marked difficulty in understanding the relationship between his substance use, mental health, and his impaired coping skills and level of functioning. For dimension 5, the patient reported use of alcohol in a severe binge-type pattern since high school. He began using a potent type of cannabis after two years of abstinence in order to manage his severe anxiety. He did not believe that he needed to be in a program of this length despite experiencing legal issues related to his alcohol use disorder and the involuntary psychiatric hospitalization from the cannabis-induced psychotic episode. The patient complained of severe anxiety during the program and the group sessions. The providers noted that the patient required help monitoring and responding to triggers as well as help with mood regulation. The patient does not recognize relapse triggers and lacks insights into the benefits of continuing care, and was therefore not committed to treatment. His continued 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 has been living in an apartment with several other roommates while in college. His social life has revolved around alcohol and cannabis use. He lacked sober supports in his living environment. The patients social network includes regular users of alcohol and other drugs such that recovery goals were assessed as unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM dimensions for the RTC services under dispute. Therefore, 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 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.