Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 28-year-old male who is requesting reimbursement for Level 3.5 substance abuse residential treatment. The records document opioid use disorder complicated by recent arm and leg fractures. The physician reviewer found that based on the records, this patient met American Society of Addiction Medicine (ASAM) Level 3.5 criteria for RTC services (ASAM 3.5) provided from 8/19/21 through 9/13/21. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. 

In terms of dimension 1, acute intoxication or withdrawal potential, the patient underwent prior withdrawal management for opioid withdrawal and had Suboxone dosage adjusted throughout his treatment stay. The patient meets the sub-criteria of awithdrawal needs can be met in Level 3.5 setting.a

In terms of dimension 2, biomedical conditions, the patient had recent orthopedic surgeries for multiple fractures. The patient meets sub-criteria of abiomedical problems, if any, are stable.a

In terms of dimension 3, emotional, behavioral, or cognitive conditions, the patient has been diagnosed with major depressive disorder and generalized anxiety disorder. He has been using 1 g of fentanyl on a daily basis. He had attempted treatment in various levels of care since April 2021 and either left against medical advice or relapsed during the programs.  He ultimately used fentanyl at a facility and then left against medical advice with another resident and fell off a wall, which resulted in significant orthopedic injuries. The patient meets sub-criteria of amental status permits participation,a and apatient demonstrated repeated inability to control his impulses to use alcohol and other drugs or to engage in antisocial behavior and is in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program.a

In terms of dimension 4, readiness to change, the patient was admitted voluntarily for treatment after his medical admission for surgery to repair orthopedic injuries sustained while relapsing at a treatment facility and falling off a wall. He has been using opiates problematically for several years. The patient had tried short-term detox with partial hospitalization program and intensive outpatient programs on multiple occasions since April 2021 and relapsed during the programs.  The patient meets sub-criteria of arequires structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery because motivational interventions have not succeeded at less intensive levels of care and such interventions are assessed as not likely to succeed at a less intensive level of care.a

In terms of dimension 5, relapse, continued use, continued problem potential, this patient has a history of multiple relapses with multiple attempts at treatment. He was managed with Suboxone during the residential treatment period. The patient meets sub-criteria of "patient is experiencing addiction symptoms such as drug cravingaThis situation poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors.a
 
In terms of dimension 6, recovery environment, he has not been able to cope without using substances outside of facilities since his last relapse, which appears to be at least one year ago. He has been actively participating in treatment program since April 2021 and relapsed either during treatment or left against medical advice. He has been unable to work due to his addiction. He has been in a relapse for months when in the home environment. The patient meets sub-criteria of apatient is unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting.a

Therefore, the patient meets ASAM criteria for inpatient residential treatment center services (ASAM 3.5) provided from 8/19/21 through 9/13/21. Therefore, inpatient residential treatment center services (ASAM 3.5) provided from 8/19/21 through 9/13/21 were medically necessary for the treatment of this patient.