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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for mental health residential treatment center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.1 criteria for Residential Treatment Center (RTC) services. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient was treated with Suboxone for opioid cravings. Before reaching the period of services at issue, the patients withdrawal was limited to cravings and insomnia. Based on clinical findings, the patients withdrawal needs could be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient has hepatitis C. The patients biomedical problems are therefore stable and do not require medical or nurse monitoring.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient was diagnosed with major depressive disorder, recurrent, and attention deficit hyperactivity disorder (ADHD). He was actively participating in groups, but he struggled with task completion. The patients mental status is sufficiently stable to permit participation in the therapies provided in the residential treatment center, and his symptoms and functional limitations (residual psychiatric symptoms and chronic addictive disorder) are sufficiently severe that he is not likely to maintain abstinence if treatment is provided in a nonresidential setting.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily due to a near overdose on fentanyl the day before admission. He has had worsening consequences of uncontrolled drug usage including relationship, housing and financial problems. He is motivated to complete the program. The patient acknowledges the existence of a substance use problem. He is also sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient has been using fentanyl, heroin, methamphetamine, and alcohol heavily for the past 10 years. He has had several past attempts at treatment beginning in 2019. The patient understands his addiction and mental disorder but he is at risk of relapse in a less structured level of care because he is unable to consistently address either or both.For dimension 6 - Recovery Environment. The patient is homeless as his mother kicked him out due to his ongoing substance usage. The patients social network is composed of drug dealers and drug users. He is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patient's living environment makes recovery unlikely and the patient has insufficient skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Using the ASAM level 3.1 criteria worksheet, the patient meets all six criteria for medical necessity and therefore qualifies for ASAM Level 3.1 treatment. Accordingly, the mental health residential treatment center (RTC) services at issue and requested services were, and are, medically necessary for this patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary for this patient's 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.