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 American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 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 underwent withdrawal management for opioid and benzodiazepine withdrawal earlier in his treatment stay. The patients withdrawal needs can be safely managed in a Level 3.1 setting. For dimension 2, the patient has type 1 diabetes and is on insulin. His blood sugars are poorly managed due to his not following a recommended diet. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring. For dimension 3, the patient has diagnoses of anxiety disorder and depressive disorder. The records note that he is impulsive and has difficulty delaying gratification. He was noted as staying up all night gaming and being late for medications and group sessions. He put a cigarette out on his hand to get laughter from his peers. He passed notes or paced around the room while in group sessions. He reported using one gram of heroin and intravenous fentanyl daily for three to five years and has a history of serious overdoses requiring Narcan. The patients mental status is stable enough to permit participation, and his symptoms and functional limitations, when considered in the context of his home environment, are sufficiently severe that he is assessed as unlikely to maintain abstinence if treatment is provided in a nonresidential setting. For dimension 4, the patient was admitted voluntarily for treatment after overdosing at his parents home, requiring Narcan. He reported using one gram of fentanyl and one gram of intravenous heroin daily, combined with Xanax daily for the past three to five years. He was noted as immature in his interactions and ambivalent about treatment. The records noted that he often stayed up late gaming and was then lethargic and late for group sessions. He reported planning on using psilocybin mushrooms and cannabis upon discharge, noting that they were organic. The patients perspective impairs his ability to make behavioral changes without the support of a structured environment.For dimension 5, the patient reported having only two days of sobriety outside of residential treatment. He reported using intravenous heroin and fentanyl daily for the past three to five years, combined with Xanax. He had a history of multiple overdoses, requiring Narcan on his most recent overdose. He had a troubled relationship with his parents due to his substance use.  The records noted poor insight into relapse triggers and continued lack of coping skills for managing urges to use. The patient is ambivalent and undecided about his aftercare plans. The patient demonstrates limited coping skills to address relapse triggers and urges and is thus in imminent danger of relapse with dangerous behavioral consequences. The patient requires 24-hour monitoring and structured support to help him apply recovery and coping skills.For dimension 6, the patient is homeless when not living with his parents. He is unemployed due to his substance use and does not have a sober support system. His longest period of sobriety outside of a residential setting has been two days. 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, and community activities. His social network involves regular users of alcohol and substances such that recover goals are assessed as unachievable at a lower level of care.Given these findings, the patient meets the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not 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, 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 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.