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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does 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 patient does not have any ongoing signs or symptoms of withdrawal. The patients drugs of choice included cannabis and methamphetamine. He subsequently had a one-time use of heroin. The patient did not have any ongoing significant signs or symptoms of withdrawal and he was not at risk of withdrawal. The patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient has chronic medical issues, including asthma and arthritis. He did not have any acute medical risk issues or treatment needs requiring treatment at the RTC level of care. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications.For dimension 3, the patient has a history of attention-deficit/hyperactivity disorder (ADHD), mood, and anxiety issues. The provider also noted concern for symptoms of psychosis during this admission and the patient reported intermittently hearing voices. However, there was no indication that he had any command hallucinations, or symptoms of psychosis that were gravely disabling or required treatment in a 24-hour setting. He also has a history of past suicidal ideation, but he has not reported any ongoing thoughts of harming himself or others during his stay. Based on these findings, the patients mental status is sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. However, the patient does not meet subcriteria (b) through (f) as the documentation does not support the presence of significant functional deficits, concomitant personality disorders, anti-social behaviors, continued psychiatric instability, or probability of imminent danger requiring continued residential care. Thus, the patient does not meet the requirements for this dimension. For dimension 4, the patient has been motivated for treatment. This is his first episode of treatment. He was urged to come to treatment by his family and he was not oppositional to being admitted. He has been educated about making behavior changes and utilizing relapse prevention skills. By the date of denial, the patient has not required structured therapy in a 24-hour programmatic milieu to promote treatment progress and recovery based on his readiness to change. Based on the clinical findings, the patient does not meet the requirements for this dimension. For dimension 5, this is the patients first episode of care. He reported that he stopped using methamphetamine approximately one week prior to admission and on admission, he only tested positive for cannabis. The patient also reportedly engaged in a single episode of heroin use for the first time with a peer at the RTC. He was remorseful about this incident and admitted it when asked about his possible intoxicated appearance. He is otherwise stabilized and learning recovery skills. By the date of denial, the patient has not demonstrated a history of repeated relapses and the inability to control to his use of substances. Based on the clinical findings, the patient does not meet the requirements for this dimension. For dimension 6, the patients family has been involved and supportive. The patient is noted to have issues with returning to his mothers house due to an incident with his brother prior to admission. The patients mother has been actively involved in his care. The patient is noted to have options such as staying with his father or in a sober living facility. The documentation does not show that the patient has been unable to cope outside of a 24-hour care, or that his social network includes significant substance use or significant social isolation or withdrawal such that his recovery goals have been assessed as inconsistently achievable at a less intensive level of care. Based on the clinical findings, the patient does not meet the requirements for this dimension. ASAM requires adult patients to meet all six dimensions to support treatment at the RTC level of care. As this patient does not meet the criteria for dimensions 3, 4, 5, and 6. Therefore, the RTC services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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 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.