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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.7 criteria for RTC substance abuse subacute detoxification services provided for three days, but she did not meet Level 3.7 criteria for RTC services for the remainder of her stay. 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, on initial presentation, the patient demonstrated symptoms consistent with significant risk of complicated withdrawal. She has a history of using heroin, benzodiazepines, and alcohol. The patients withdrawal required ASAM Level 3.7 setting. The patient did well with the detoxification protocol at the facility. The patient had no significant ongoing signs or symptoms of withdrawal. She was no longer at risk for complicated withdrawal requiring treatment in a 24-hour residential detoxification setting. The patient met the requirements for ASAM Level 3.7 for three days. For dimension 2, the patient is medically stable. The patients biomedical condition required 24-hour nursing and medical monitoring or active treatment, but not the full resources of an acute hospital. After three days, she no longer required Level 3.7 services and her biomedical conditions could have been managed at a lower level of care. She complained of back and abdominal pain, which she attributed to endometriosis. She was referred to an emergency department for evaluation. Overall, she was medically stable. Thus, the patient no longer met the requirements for this dimension for Level 3.7 services.For dimension 3, the patient has a history of multiple psychiatric diagnoses including PTSD, major depressive disorder, and generalized anxiety disorder. She reported a history of past trauma. The provider noted that the patient appeared depressed at times. She was not suicidal with intent or plan, self-injurious, homicidal, aggressive, or acutely psychotic. Based on the documentation provided, the patient exhibited stress behaviors associated with recent losses in family domains. The patient thus required a secure, medically monitored environment in which to address self-care problems and focus on her substance use and behavioral health problems. The patient no longer met the requirements for Level 3.7. For dimension 4, the patient presented voluntarily. However, she has a history of poor compliance with treatment and significant issues with prior care. She demonstrated a limited understanding of consequences from her substance use. The patient required structured therapy in a 24-hour programmatic milieu to promote treatment progress for substance abuse residential rehabilitation, but she did not meet the requirements for Level 3.7 services after three days of treatment.For dimension 5, the patients records documented two prior episodes of care. In 2020, she left treatment because she was the only female. She also had another attempt at treatment earlier in 2021, but she brought in substances and was asked to leave the program. Based on the clinical findings, the patient did not recognize relapse triggers and lacked insight into the benefits of continuing care. After three days, the patient no longer met the requirements for this dimension for Level 3.7 services. For dimension 6, the patient was homeless prior to admission. She had a difficult phone call with her boyfriend during her stay. She appeared to have limited sober supports. After three days, the patient no longer met the requirements for this dimension for Level 3.7 services. The patient met the requirements for ASAM Level 3.7 substance abuse subacute detoxification services for three days. However, the patient did not meet the requirements for ASAM Level 3.7 RTC services for three days. The services were not in accordance with the appropriate in terms of type, frequency, and duration. Therefore, the RTC services provided at Fresh Start of California for three days were medically necessary for treatment of this patient, and the remainder of the RTC services provided were not medically necessary. Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification 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.