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

An enrollee has requested authorization and coverage for residential treatment center services.The submitted documentation supports that residential treatment center services were, and are, medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. Notes document that the patient fulfilled criteria for Dimension 1, as they indicate that the patient entered into treatment displaying multiple substance use disorders and withdrawal and that he was still experiencing symptoms of withdrawal as evidenced by Clinical Opiate Withdrawal Scale (COWS) and Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWAS) scoring. For dimension 2, biomedical conditions and complications, the patient has poor sleep and appetite and is noted to have medication issues that are being monitored for safety. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patients comorbid obsessive compulsive disorder, binge eating disorder and major depressive disorder fulfill this dimension. For dimension 4, readiness to change, the patient states that the negative attention from using is better than sobriety as it shows that he is noticed by others. The patient also attributes his use to environmental factors rather than seeing his own autonomy. For dimension 5, relapse, continued use, or continued problem potential, the patient, in discussion, states that he continues to choose substance use over sobriety. For dimension 6, recovery environment, records indicate that the patient socializes with substance users and has unstable, unsupportive abusive romantic relationships. The submitted documentation thereby reflects that the patient requires a safe and stable living environment in order to develop his recovery skills, thus qualifying for ASAM Level III treatment at least, which is similar to what the patient has received at the facility. ASAM criteria note that it is not intended that all, or even the majority of social and psychological problems will be resolved in a Level 3.5 treatment stay. Treatment may be required at Level 3.5 if an individual is not progressing and faces imminent danger if not in a supportive 24-hour treatment setting. Given the severity of the patients illness, residential treatment center services were, and are, clinically appropriate for the patient's illness. Therefore, residential treatment center services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services in issue and requested services were, and are, 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.