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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the residential treatment center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met 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 was noted to have withdrawal symptoms of anxiety, agitation, and tremors. He was using fentanyl, Xanax, and cannabis daily and had previously attempted detoxification but relapsed. The patient was managed on a Librium taper. The patients withdrawal needs were safely managed in level 3.5 setting. For dimension 2, the patient did not have biomedical problems and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with anxiety and ADHD. He had been using alcohol, Xanax, cannabis, and alcohol to manage his symptoms. He reported loss of employment and relationships, and struggles with education, due to his substance use. He lived with friends and his parents and was unable to live independently. He had difficulty focusing on and completing assignments during his stay at the RTC.  The patients mental status was stable enough to permit participation and he had significant functional deficits of a pervasive nature that were sufficiently severe that the patient was not likely to maintain abstinence if treatment was provided in a non-residential setting. For dimension 4, the patient overdosed on fentanyl two months prior to admission and reported he was unable to maintain sobriety. He reported blackouts due to combining Xanax and alcohol. He was unemployed, had dropped out of school, and been unable to maintain relationships due to his substance use. Despite experiencing serious consequences, the patient had marked difficulty in understanding the relationship between his substance use, mental health, or life problems and his impaired coping skills and level of functioning, often blaming others for his addiction problems. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions had not succeeded at less intensive levels of care. For dimension 5, the patient had tried to quit substance abuse at least ten times. He had tried therapy with vivitrol. He had a history of treatment at RTC and PHP levels of care and detoxification attempts, but had subsequently relapsed. At the RTC, he had difficulty completing group assignments and focusing in group sessions. Despite recent, active, participation in treatment at a less intensive level of care the patient continued to use drugs with imminent serious consequences and was at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient had unstable housing with his parents and his friends. He was unemployed and had dropped out of school due to his substance use. He was using substances daily, and was unable to stop substance use on his own, having tried unsuccessfully to quit substance use ten times. He had failed therapy with vivitrol. The patient was unable to cope, for even limited periods of time, outside of 24-hour care such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, all of the RTC services provided at The Lakes Treatment Center were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were 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.