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) services.  Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 was admitted to RTC two weeks after last use as she was transferred from jail. The patients withdrawal needs can be met in Level 3.1 setting. For dimension 2, the patient does not have active medical problems. The patients biomedical problems, if any, are stable and do not require medical or nurse monitoring. For dimension 3, the patient has a significant history of trauma and abuse. The provider noted that the patient participated in groups. The patients mental status is assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition is stable and she is assessed as having minimal problems in this area as evidenced by anxiety may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment and the patient is assessed as not posing a risk of harm to self or others. For dimension 4, the patient was directed to attend RTC pursuant to a court order. She has expressed a desire to remain clean and abstinent. The patient has been able to identify negative consequences of her addiction, including incarceration. The patient acknowledges the existence of a substance use problem. The patient recognizes specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been using heroin and methamphetamine daily since age 18. She has undergone prior attempts at treatment and relapsed. She has a number of stressors that are considered relapse triggers including homelessness, unemployment, and probation obligations. She has history of multiple prior overdoses on opioids. The patient demonstrates limited coping skills to address relapse triggers and urges. She is in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient recently lost her job due to incarceration related to her substance use disorder. She is also homeless, and her social network consists of other substance users. The patient is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC 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 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.