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 3.1 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 and managed for withdrawal with a five-day Librium taper. The patients withdrawal symptoms subsided by the dates of this treatment review. The patients withdrawal needs could have been met in Level 3.1 setting. For dimension 2, the patient underwent extraction of several teeth while he was at the RTC and his treatment was complicated by his post-procedure pain. The patients biomedical problems were stable and did not require medical or nurse monitoring and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has history of childhood trauma due to physical abuse. The patient reported having difficulty with anger and intermittent passive suicidality. He participated in individual therapy and group sessions. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition was stable and he was assessed as having minimal problems in this area as evidenced by both of the following: (1) the patients depression may be related to substance use problems or to a stable co-occurring emotional condition with imminent likelihood of relapse with dangerous consequences outside of a structured environment and (2) the patient was assessed as not posing a risk to self or others. For dimension 4, the patient admitted himself for treatment due to unsuccessful attempts to stop his polysubstance usage on his own. The patient presented with depression, anger problems, and passive intermittent suicidality. He expressed a desire to become abstinent and he was able to identify negative consequences of his substance usage including mental health problems, occupational problems, and relationship problems. The patient acknowledged the existence of a psychiatric condition and substance use problems. The patient recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient was abusing multiple substances including alcohol, Xanax, Vicodin, cocaine, and methamphetamine on a near daily basis for the past five years. He has no history of abstinence despite trying to stop using on his own. He worked to develop an awareness of relapse triggers and coping skills for managing urges to use. The providers noted that the patient experienced difficulty maintaining interest in his recovery and that he expressed that he could drink alcohol and use cannabis on occasion. The patient needed staff support to maintain engagement in his recovery program while transitioning to life in the community. For dimension 6, the patient lives with his parents. His father is an alcoholic and drinks at home. The records document that the patient blamed his father for his own difficulties with substance use. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. The patient was living in an environment that is characterized by the risk of repetition of physical or emotional abuse, or substance use so endemic that the patient was assessed as being unable to maintain recovery at a less intensive level of care. Given these findings, the patient met the six ASAM dimensions for RTC services. For these reasons, the RTC level of care 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 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.