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 3.5 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 managed for sedative-hypnotic withdrawal with a Librium taper. He was also tapered off Klonopin that was indicated to treat his seizure disorder. The patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2, the patient has history of complex partial seizures and he is status post hippocampal surgery. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring and the patient was capable of self-administering any prescribed medications.For dimension 3, the patient has a psychotic disorder, generalized anxiety disorder, and agoraphobia. He was noted to have delusions about recent events and to have problems with reality testing. He was noted to be paranoid with delusions about people hacking him and putting items under his skin. These psychotic symptoms were distressing, and he was using substances to manage his anxiety. The patients mental status was 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 patient has significant functional deficits which were likely to respond to staff interventions. These symptoms were sufficiently severe that the patient was not likely to maintain abstinence if treatment was provided in a non-residential setting. The functional deficits were of a pervasive nature, required treatment that is primarily habilitative in focus, and did not require medical monitoring or management. They included residual psychiatric symptoms. For dimension 4, the patient was admitted to RTC as his mother was no longer able to manage him due to his delusions and inability to function. His psychosis was exacerbated by his ongoing amphetamine use. He has been unemployed and living with his mother due to his substance abuse problems. He has been using methamphetamine daily since age 11. Because of the intensity and chronicity of the addictive disorder, he had limited insight and little awareness of the need for continuing care or the existence of his substance use and need for treatment, and thus had limited readiness to change. For dimension 5, the patient experienced difficulty with maintaining sobriety outside of a controlled or structured setting. He remained psychotic with little insight into his condition and the role that amphetamine plays in relation to his symptoms. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care. He was therefore not committed to treatment. His continued substance use posed an imminent danger of harm to himself in the absence of 24-hour monitoring and structured support. For dimension 6, the patient was homeless since he was unable to return home due to the severity of his symptoms and frequency of relapses. He has been unemployed since 2015 and he has legal issues related to his ongoing substance use. The patient was unable to cope, for even limited periods of time, outside of 24-hour care. He needed staff monitoring to learn to cope with dimension 6 problems before being transferred to a less intensive setting. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.