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) (ASAM Level 3.5) services. Findings:  The physician reviewer found that 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 went through withdrawal management in her initial treatment prior to transfer to the RTC. The patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient does not have any medical problems. 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 was admitted voluntarily for treatment after losing custody of her son due to ongoing methamphetamine use. The patient has reportedly disappeared for weeks at a time while on a methamphetamine binge. Three years ago, the patient reportedly made suicidal statements while using substances and she was placed on an involuntary hold. The provider noted that the patient was crying, depressed, and reported feeling worthless. The patient was unable to manage distress or cope with her problems. She has a history of placing herself in risky situations when using substances such that she is potentially a danger to herself. 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. In addition, the patient has demonstrated repeated inability to control her impulses to use alcohol and other drugs or to engage in antisocial behavior and was in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction was of such severity that it precluded participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient lost custody of her son due to her alcohol and substance use disorders. The patient expressed that she did not fully understand why she lost custody despite leaving her son for weeks at a time and being intoxicated and incapacitated while her son was under her care. The patient reported being extremely depressed over losing custody of her son and had poor insight into the impact of her addiction on her ability to parent. The patients substance and alcohol usage had escalated in the setting of recent trauma of being raped and the recent death of her friend. The provider noted that she lacked basic coping skills to emotionally regulate herself. Despite experiencing serious consequences or effects of the addictive disorder, the patient has marked difficulty in understanding the relationship between her substance use, addiction, mental health, or life problems and his impaired coping skills and level of functioning. For dimension 5, this is the patients second attempt at treatment. The records document that the patient underwent one week of treatment. The patient has steadily escalated her substance usage after she relapsed a few years after her son was born and over the past two years. The patient was severely depressed and continued to be emotionally dysregulated. The patient was unable to identify relapse triggers without crying. The providers indicated that the patient was at extremely high risk of relapse due to her emotional lability. She has history of blackouts and putting herself in risky situations. The patients psychiatric condition was stabilizing. However, despite her best efforts, the patient was unable to control her use of drugs, with attendant probability of harm to self or others. The patient has limited ability to interrupt the relapse process or continued use. Her continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient has unstable housing and has been staying with friends that use drugs. She does not have a sober support system. She has lost custody of her son due to her substance use disorders. The patient has not worked in two years due to her addictions. The records document that the patients social network includes regular users of alcohol and other drugs, such that recovery goals are assessed as unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for Level 3.5 RTC services. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the RTC (ASAM Level 3.5) 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.