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

Findings:  The physician reviewer found that : The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria this patient meets Level 3.5 criteria for RTC services. The 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 underwent withdrawal management for alcohol withdrawal earlier in treatment stay. The patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient has a history of alcohol withdrawal seizures. 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 significant history of mood instability, anxiety, and psychosis. The patient has a history of nine suicide attempts with the most recent one on the day prior to admission when coming off of methamphetamine. The patient has reported auditory hallucinations and visual hallucinations subsequent to methamphetamine use. The patient has continued to have cravings, auditory hallucinations and visual hallucinations, and mild paranoia. The patient was noted to have difficulty with managing distress tolerance without using substances. The patients mental status has been assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. Despite the patients best efforts, the patient has been unable to control use of alcohol and/or other drugs with attendant probability of attendant danger. The resulting level of dysfunction is so severe that it precludes the patients participation in a less structured and intensive level of care. For dimension 4, the patient was admitted voluntarily for treatment after driving on the wrong side of the freeway due to mental state. The patient has been unemployed and living in a car for the past six months. The patient has endorsed daily use of methamphetamine and drinking alcohol heavily to the point of blackouts for six months. The patient previously tried to stop drinking for a short period of time and then celebrated by drinking alcohol. The patient has a history of suicide attempts when going through methamphetamine withdrawal. The patient was noted to lack coping skills to prevent relapse. The records document that despite experiencing serious consequences or effects of the addictive disorder, the patient has marked difficulty in understanding the relationship between substance use, addiction, mental health, or life problems and impaired coping skills and level of functioning. For dimension 5, the patient was managed for alcohol withdrawal earlier in treatment stay and continued to have withdrawal symptoms and cravings. The patient has also demonstrated significant psychiatric symptoms of anxiety, mood instability, and hallucinations that have persisted during stay. The patient was started on psychotropic medications and the dosage has been adjusted during the RTC treatment period. The provider noted that the patient lacks basic distress tolerance skills such that the patient would be unable to manage these symptoms without relapse in the community. The patient is experiencing addiction symptoms such as drug craving. This situation poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors. For dimension 6, the patient has been unable to cope without using substances over the past year and has been unemployed and living in a car for six months. The patient lacks a sober support system and seems to be socially isolated. The patient attempted to stop drinking on own within the past few months and was unsuccessful. The patient has been unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for Level 3.5 RTC services. In addition, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the RTC services (ASAM Level 3.5) were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.