Appeal type: Medical Necessity
Decision: Overturned 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) (ASAM 3.1) level of care services. Findings:  The physician reviewer found that Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC (ASAM 3.1) level of care services. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. 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 was initially treated for sedative-hypnotic withdrawal with Librium in his treatment stay and he was maintained on Suboxone. Based on the clinical findings, the patients withdrawal needs can be safely managed in a Level 3.1 setting. For dimension 2, the patient has insulin dependent diabetes mellitus, and he is on daily insulin. The records indicate that the patients biomedical problems are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient was admitted following positive drug screen administered due to legal problems related to his substance use disorder. The patient was using substances despite being mandated to treatment and having regular urine drug screens. The provider described the patient as impulsive and experiencing cravings to use substances despite severe legal consequences. The patient has been using substances daily since adolescence and he lacks coping skills or knowledge of his relapse triggers. The patient has sustained limited time in sobriety outside of being incarcerated. The provider noted that the patient has participated in groups. The patients mental status has been assessed as sufficiently stable to permit participation and the patient demonstrates an inability to maintain stable behavior over a 24-hour period without the structure and supervision of a 24-hour setting. For dimension 4, the patient was agreeable to admission following a urine drug screen positive for fentanyl. The patient reportedly relapsed shortly after discharge from a previous RTC stay. The patient has not successfully participated in outpatient treatment. There is evidence that the patient requires a 24-hour structured milieu to promote treatment progress and recovery, because motivating interventions have failed in the past and such interventions are assessed as not likely to succeed in an outpatient setting. For dimension 5, the patient has been using fentanyl and Xanax daily for most of the past two years. The patient relapsed two days after discharge from RTC. The patient reports having multiple blackouts while using substances. The patient has experienced significant legal consequences due to his substance use disorders. The records support that the patient needs staff support to maintain engagement in his recovery program while transitioning to life in the community. For dimension 6, the patient was living with his parents, but he is not allowed to return to their home due to his substance use disorders. The patients group of friends use substances, and he has experienced significant legal consequences as a result of his substance use disorders. The provider charted that the patient has little knowledge of coping skills or relapse triggers. The patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities. In addition, the patients social network involves regular users of alcohol and drugs such that the patients recovery goals are assessed as unachievable at a less intensive level of care. Moreover, the RTC services were and 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. All told, the RTC (ASAM 3.1) level of care services 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. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in in addiction medicine 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.