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

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for any or all of the residential treatment center (RTC) services provided by Olympia House.Per 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 was monitored for symptoms of withdrawal. The records did not document a history of complicated withdrawal, including delirium tremens or withdrawal seizures. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient had a history of a torn meniscus. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported some symptoms of anxiety, particularly around relationship issues. She reported being unfaithful to her wife and to her boyfriend, and that they did not want her to return home and had moved her belongs to her parents house. She reported feeling that continued contact with her partners was distracting her from treatment. She had a history of participating in outpatient therapy and was on Lexapro. The patients level of emotional, behavioral, or cognitive conditions and complications is not consistent with the Level 3.5 guidelines, as the patient did not demonstrate repeated inability to control impulses, unstable and dangerous signs or symptoms requiring stabilization, functional deficits requiring stabilization in a 24-hour setting, or a co-occurring severe and chronic mental illness consistent. This criteria is not met.For dimension 4, the patient admitted herself to treatment voluntarily. She was motivated for recovery, honest and forthcoming with details related to her treatment history and recognized negative consequences from her use prior to her presentation. The records did not document marked difficulty with, or opposition to, treatment with dangerous consequences. The patient did not require structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery. This criteria is not met.For dimension 5, the patient had a limited history of prior treatment, including outpatient therapy. The documentation did not note that the patient lacked recognition of the skills needed to prevent continued use with imminent serious consequences, or that she was at high-risk of continued use in the absence of close 24-hour monitoring and structured treatment. This criteria is not met.For dimension 6, the patient had some support from family, including her brother and her parents. Both her wife and boyfriend initially participated in family sessions. Her parents continued to have some involvement in the patients care, as the patients partners had sent her belongings to her parents house. The patients wife was planning to file for divorce. The patients environment was not dangerous, and the patient did not lack coping skills such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. This criteria is not met.Given these findings, the patient did not meet the six ASAM criteria for RTC services provided by Olympia House. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, RTC services provided by Olympia House were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.