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 from 8/3/20 to 9/24/20. 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 drinking six beers per day and using cannabis on a daily basis. He was monitored for withdrawal from alcohol. The patients withdrawal needs could have been met in Level 3.5 setting.For dimension 2, the patient does not have any medical problems. The patients biomedical problems, if any, are stable and do 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 been diagnosed with bipolar disorder, most recent episode manic with psychotic features. His manic episode was precipitated by increasing daily cannabis usage. He was hostile and aggressive with his mother at home such that she left the home for two weeks. This was a new behavior for him. He was able to participate in groups. He was noted to express ongoing delusional thoughts while at the RTC. 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 are likely to respond to staff interventions. These symptoms and deficits, when considered in the context of his home environment were sufficiently severe that the patient was not likely to maintain abstinence if treatment was provided in a non-residential setting. The functional deficits are of a pervasive nature and include residual psychiatric symptoms. For dimension 4, the patient was admitted at the request of his father after demonstrated hostility and aggression toward his mother in the family home for the two weeks prior to admission. His most recent manic episode was likely precipitated by increasing and excessive cannabis usage. He has been unemployed and unable to see his nine-month-old child due to his substance abuse problems. He is living with his parents. He has been using cannabis and alcohol daily. Despite experiencing serious consequences of the addictive disorder, 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. For dimension 5, the patient has not wanted to stop using cannabis and alcohol daily despite worsening of his psychiatric condition and development of a manic episode with psychotic features. Prior to admission, the patient was in outpatient therapy and had a sober companion that were not helpful. He was aggressive at home with his mother. Despite recent, active participation in treatment at a less intensive level of care, the patient continued to use alcohol and cannabis and deteriorate psychiatrically with imminent serious consequences and was at high risk of continued substance usage or mental deterioration in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient lives at home with his parents and has been hostile and aggressive toward his mother. He was unwilling to stop using alcohol and cannabis prior to RTC admission. He demonstrated poor insight into the role of his cannabis use in precipitating his manic symptoms. 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 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.