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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for (1) residential treatment center (RTC) services and (2) RTC services. Findings:  The physician reviewer found that this patient met 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 was admitted to the RTC following detoxification treatment. The patients withdrawal needs were safely managed in a level 3.1 setting. For dimension 2, the patient had severe, chronic pain for which he was prescribed opioids. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported symptoms of depression, treated with Pristiq for several years, and anxiety. While at the RTC, the patient trialed different medications to assist in his sleep, mood, and anxiety. He participated in group sessions. The patients mental status was stable enough to permit participation, and his co-occurring psychiatric conditions were addressed concurrently through appropriate psychiatric services.For dimension 4, the patient reported admitting himself for alcohol and opioid use disorder treatment because he was confronted regarding his alcohol use by his family. He expressed a desire to become abstinent and was able to identify negative consequences of his alcohol and opioid usage including family discord and financial consequences. The patient recognized specific negative consequences and dysfunctional behaviors and was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient reported drinking up to one and a half liters of vodka and taking up to 100 mg of hydrocodone daily. He had initially been prescribed opioids for chronic neck pain after a surgical procedure. While at the RTC, he was introduced to cognitive behavioral therapy (CBT) as a coping strategy to manage his pain. Despite understanding his addiction and mental disorder, the patient was at risk of relapse in the absence of close 24-hour monitoring and structured treatment as he was unable to consistently address both. For dimension 6, the patient lived with his wife, who drank wine, and his son, who used cannabis. The patients social network involved living in an environment that was so highly invested in alcohol or other drug use such that recovery goals were assessed as unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not 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 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 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.