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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for RTC services (to complete a 28-day RTC program) at 10 Acre Ranch.Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria. 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 reported using kratom daily until admission to the RTC and using  codeine daily for two weeks prior to admission. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had hypertension and a history of mercury poisoning. 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 and anxiety and feelings of guilt. The records did not note that the patient was suicidal or homicidal and did not document functional deficits. The patient participated in group sessions. The patients mental status was stable enough to permit participation. The records did not document that the patient was unable to control his use of substances with attendant probability of imminent danger. The patient did not demonstrate repeated inability to control his impulses to use substances with imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrate antisocial behavior patterns, have significant functional deficits of a pervasive nature requiring treatment that was primarily habilitative in focus and likely to respond to staff interventions without requiring medical monitoring and management, or have concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provided opportunities to promote continuous boundary setting interventions. This criterion was not met.For dimension 4, the patient admitted himself to treatment voluntarily. He participated in his treatment. The records did not document that the patient had limited insight and little awareness of the need for continuing care or marked difficulty in understanding the relationship between substance use, mental health, or life problems and impaired coping skills and level of functioning, blaming others for his addiction problems. The patient did not 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, have a perspective impairing his ability to make behavior changes without repeated, structured motivational interventions, express little to no interest in changing, or attribute his alcohol, drug or mental health problem to other persons or external events. This criterion was not met. For dimension 5, the patient reported using up to 200 mg of codeine until two weeks prior to his admission to the RTC along with a kratom daily up until admission. The patient reported opioid usage for the past two years. This was his first attempt at treatment. The records did not note a history of suicidal or homicidal ideation. He was not aggressive and there were no concerns noted regarding harm to self or others. The patient did not lack insight into the benefits of continuing care leading to a lack of commitment to treatment. He was not unable to control substance use with attendant probability of harm to self or others, or experiencing 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. The patient was not in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, was not continuing the use of substances despite recent active participation in treatment at a less intensive level of care and did not demonstrate a lifetime history of repeated incarceration. This criterion was not met.For dimension 6, the patient lived with his wife and children and owned a scrap metal business. The patient did not live in an environment characterized by a moderately high risk of neglect, abuse or substance use so endemic that recovery was assessed as unachievable at a less intensive level of care, or have a social network including regular users of drugs, addicted users, or dealers of alcohol or other drugs such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. The patient was not characterized by significant social isolation and withdrawal, such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care or unable to cope, for even limited periods of time outside of 24-hour care. This criterion was not met.Given these findings, the patient did not meet the six ASAM criteria. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, RTC services received from 4/16/21 through 5/2/21 (to complete a 28-day RTC program) at 10 Acre Ranch were 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.