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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 patients withdrawal needs can be safely managed in a Level 3.1 setting. The patient is no longer in active withdrawal from substances and he has denied suicidal ideation and paranoia. For dimension 2, the patient has diabetes with poor blood sugar control. His blood sugars were erratic, and he has required frequent medical monitoring. He is currently receiving adequate services. The patients biomedical condition is not severe enough to warrant inpatient treatment but is sufficient to distract from treatment or recovery efforts. The problem requires medical monitoring, which can be provided by the program. For dimension 3, the patient has exhibited poor impulse control outside of a structured environment. He continues to show symptoms of depression and anxiety. His providers noted a history of impulsivity, difficulty controlling urges, legal issues, and problems with authority. The patients mental status is 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 patient demonstrates through impulsivity an inability to maintain stable behavior over a 24-hour period without the structure and support of a 24-hour setting. For dimension 4, the patient is motivated to change yet he requires support and structure in navigating the stages of change. The patient acknowledges the existence of a psychiatric condition and substance use problem. He recognizes specific negative consequences and dysfunctional behaviors and their effect of his desire to change. The patient is sufficiently ready to change and cooperative enough to respond to treatment at Level 3. 1. For dimension 5, the patient has relapsed multiple times and continues to require 24-hour support to acquire the coping skills needed to maintain sobriety. The patient continues to demonstrate limited coping skills to address relapse triggers and urges. He is in imminent danger of relapse, with dangerous emotional, behavioral, and cognitive consequences, and needs 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patients family has been supportive, but they are noted to enable the patients substance use disorder. The patient has demonstrated limited coping skills but is motivated and recovery is possible with adequate treatment structure. The patient is able to cope, for limited periods of time, outside of the 24-hour structure of a Level 3.1 program in order to pursue community activities. Continued exposure to the patients living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. These findings demonstrate that the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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.