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) (ASAM 3.5) level of care. Findings:  The physician reviewer found that (ASAM) criteria, this patient did not and 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 was noted to have some withdrawal symptoms. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient had hypertension and a severely severed tongue from a seizure. He was on a diet of soft foods. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had diagnoses of unspecified depressive disorder and unspecified anxiety disorder. The records did not note that he was suicidal, self-injurious, homicidal, aggressive, or psychotic. The patient reported some feelings of shame about relapsing but did not demonstrate antisocial behavior patterns, significant functional deficits, or personality disorders requiring RTC level of care. While the patients mental status permits participation, the records did not reflect that his symptoms and history precluded participation in a less structured or intensive level of care. This criteria is not met. For dimension 4, the records noted that the patient reported motivation to change and recognized negative consequences from alcohol and substance use. In this case, the documentation did not support that the patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery or that motivational interventions had not succeeded. This criteria is not met.For dimension 5, the patient had a history of relapse with escalating use after the loss of his brother. He was able to recognize relapse triggers and was motivated for recovery. He was started on naltrexone to manage cravings. In this case, there is a lack of evidence that the patient continued to use or was at high-risk of continued substance use despite recent, active participation in treatment at a less intensive level of care. This criteria is not met.For dimension 6, the patient was living with a roommate who used cannabis. The patients social network involved living with an individual who was a regular user such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient did not and does not meet the six ASAM criteria RTC level of care. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were and are primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, 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 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 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.