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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for residential treatment center (RTC) services (ASAM Level 3.5) provided from 6/16/21 forward at Olympia House.At issue is whether RTC services (ASAM Level 3.5) provided from 6/16/21 forward at Olympia House were and/or are medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A).Per the American Society of Addiction Medicine (ASAM) criteria, this patient met and meets Level 3.5 criteria for RTC services provided from 6/16/21 forward. 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 underwent withdrawal management with diazepam for alcohol withdrawal. The patients withdrawal needs could have been safely managed in a Level 3.5 setting.For dimension 2, the patient does not have any active medical problems of significance. The patients biomedical problems, if any, were stable and did not require medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications.For dimension 3, the patient has been diagnosed with bulimia and depression. The patient reports that she has been drinking one liter of vodka daily for two years. This is her third RTC admission since March 2021. She has relapsed within days of returning to her home environment each time despite being set up with an aftercare plan. In May 2021, the patient was arrested for DUI and child endangerment as her two children were in the car. The patient is still struggling with urges to drink and is undergoing medication adjustment. 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. Additionally, the patient meets other qualifying criteria for this dimension, including unable to control her use of alcohol and drugs with attendant probability of imminent danger, demonstrates repeated inability to control her impulses to use alcohol and to engage in antisocial behavior and is in imminent danger of relapse with attendant likelihood of harm to self or others. Based on these findings, the patient meets the requirements for this dimension.For dimension 4, the patient was admitted voluntarily for treatment, but this is mostly due to external pressure from her husband, legal charges, and having an open case with CPS. The patient meets the requirements for this dimension, including limited insight and little awareness of the need for continuing care, demonstrated passive or active opposition to addressing the severity of her addiction problem, and required structured therapy and a 24 hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care. Based on these findings, the patient did meet the requirements for this dimension.For dimension 5, this is the patients fourth attempt at residential treatment level of care. The patient drinks to the point of blackouts. She is still noted to lack coping skills to avoid relapse. She continues to have a high level of cravings for alcohol. She is having difficulty coping with marital problems and the anxiety around being investigated by CPS due to the child endangerment charges. The patient meets the requirements for this dimension, including lack of insight into benefits of continuing care, in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, and despite recent active participation in treatment at a less intensive level of care, the patient continued to use alcohol or drugs. Based on these findings, the patient meets the requirements for this dimension.For dimension 6, the patient is married and previously lived with her husband and two small children. The patient has been a stay at home mom. Her husband is threatening divorce due to her drinking and is stipulating that she be discharged to a sober living environment (SLE), which she has now accepted. She is having difficulty finding an SLE that is close to her residence. She does not have friends or family support. She has been drinking daily unless in a treatment center and has previously relapsed within a few days of discharge, which resulted in grave consequences of her driving while intoxicated with her small children. She now has additional stressors of legal charges. The patient meets the requirements for this dimension. The patient is to unable cope, for even limited periods of time, outside of 24-hour care. Based on these findings, the patient meets the requirements for this dimension. The ASAM criteria requires adult patients to meet all six dimensions to support RTC services. This patient did meet all the dimensions for Level 3.5 RTC criteria. Moreover, the services were and are in accordance with the generally accepted standards of mental health and substance use disorder care. The services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not 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. Given these findings, the RTC services (ASAM Level 3.5) provided from 6/16/21 forward at Olympia House 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 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.