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 residential treatment center (RTC) level of care services. Findings:  The physician reviewer found that 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 withdrawal. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient had type 1 diabetes, with blood sugars documented nearing his baseline level of blood sugar management. His blood sugars continued to fluctuate but were improving. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was psychiatrically stable and while he was noted early on in treatment to be irritable and aggressive, the patient was not suicidal, self-injurious, homicidal, or psychotic. The records noted that the patient became more engaged and participated in treatment, attending sessions and participating appropriately. The patients mental status was stable enough to permit participation, he was able to control his use of substances and impulses and did not demonstrate antisocial behavior patterns, significant functional deficits, or concomitant personality disorders that would preclude participation in a less structured and intensive care. This criteria was not and is not met.For dimension 4, the patient presented voluntarily for treatment. While he was initially noted to be resistant to some treatment recommendations, his engagement and compliance improved over time. He recognized the negative consequences of his substance use. The patient did not require structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, as he was sufficiently motivated for recovery. This criteria was not and is not met.For dimension 5, the patient was motivated, engaged, and working on preventing relapse, maintaining sobriety from methamphetamine and cannabis. He was able to actively participate in the relapse prevention process. The patient was not at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. This criteria was not and is not met.For dimension 6, the patient identified his godmother and aunt as his primary supports. The patient planned to live with one of his sober supports, such as his godmother or an aunt, and was encouraged to consider a sober living environment. The records did not indicate that the patient could not cope outside of a structured 24-hour environment, or was planning to reside in a living environment, or interact with a with a social network, which was unsupportive of his goals of maintaining sobriety. This criteria was not and is not met.Given these findings, the patient did not and does not meet the six ASAM criteria for RTC services. 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, RTC level of care services 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.