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 all or any of the residential treatment center (RTC) services (ASAM Level 3.5). Per American Society of Addiction Medicine (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 did not have ongoing signs or symptoms of significant withdrawal. The patients withdrawal needs were safely managed in a Level 3.1 setting. For dimension 2, the patient did not have active comorbid medical issues. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring.For dimension 3, the patient reported constant and distressing auditory hallucinations prior to entering treatment. He was unable to concentrate or problem-solve due to the voices. He had been drinking and using methamphetamines heavily for the past seven to ten years. The patient lacked knowledge of his relapse triggers and lacked coping skills to manage his auditory hallucinations and relapse triggers without resorting to substance use. The patient participated in group sessions. The patients symptoms of psychosis did not pose a risk of harm to himself or others and were not gravely disabling. The patients mental status was stable enough to permit participation. He did not have an inability to control his use of alcohol and drugs with attendant probability of imminent danger or demonstrate repeated inability to control his impulses to use alcohol and other drugs. He did not have ongoing issues related to impulsivity, antisocial behavior, functional impairment, or personality disorders, was not in imminent likelihood of relapse with dangerous consequences outside of a structured environment and did not pose a risk of harm to himself or others. This criterion is not met.For dimension 4, the patient admitted himself to treatment voluntarily due to ongoing distressing auditory hallucinations, secondary to his methamphetamine use, that persisted despite his reportedly being substance free for the past month. He acknowledged negative consequences of his substance usage, including legal problems and psychiatric problems. He was focused on eliminating the voices in his head and actively participated in his treatment. The records did not reflect that the patient had limited insight and awareness of the need for continuing care, marked difficulty in understanding the relationship between his substance use, mental health, or life problems and his impaired coping skills and level of functioning. The patient did not blame others for his addiction problems, demonstrate passive or active opposition to addressing the severity of his addiction problem, require structured therapy and a 24-hour programmatic milieu because motivational interventions had not succeeded at less intensive levels of care, or display a perspective impairing his ability to make behavior changes without repeated, structured motivational interventions. This criterion is not met. For dimension 5, the patient reported drinking a half gallon of alcohol daily along with daily methamphetamine use for the past seven to ten years. He reported being clean for the month prior to admission but struggling with urges to use due to the severity of auditory hallucinations. The records noted that the patient continued to be bothered by voices throughout his RTC stay but saw some degree of improvement with medication. He reported ongoing urges to use to cope with the distress of hearing voices and had difficulty maintaining focus on his substance treatment at times due to the distressing nature of the hallucinations. The patient did not endorse suicidal or homicidal ideation. He was compliant with and tolerated appropriate psychotropic medications, including long-acting injectable antipsychotic medication. The records do not indicate that the patient lacked insight into the benefits of continuing care affecting his commitment to treatment, an inability to control use of alcohol or drugs with attendant probability of harm to self or others, cravings with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, continuation of the use of alcohol or drugs despite recent active participation in treatment at a less intensive level of care, or a lifetime history of repeated incarceration. This criterion is not met.For dimension 6, the patient was living with his parents and had been unemployed for the past year. The patient reported that his stepfather drank alcohol daily. The patient reported social isolation due to his auditory hallucinations and did not appear to have a sober social support network. He was reported as having limited knowledge of coping skills or relapse triggers.  The patient's social network was characterized by significant social isolation and withdrawal, such that recovery goals are 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 for RTC services (ASAM Level 3.5). 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 (ASAM Level 3.5) 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 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.