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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the 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 patients withdrawal needs were met in Level 3.5 setting. The patient continued to report withdrawal symptoms of agitation, anxiety, insomnia, and cravings. For dimension 2, the patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of administering any prescribed medications. For dimension 3, the patient has diagnoses of bipolar 2 disorder versus major depressive disorder as well as significant anxiety. She was unable to control her usage of fentanyl and she had a near-fatal overdose immediately prior to admission. She participated in groups and underwent medication adjustments. The patients mental status permitted participation. Her psychiatric condition was stabilizing. However, despite the patients best efforts, she was unable to control her use of drugs with attendant probability of imminent danger. For dimension 4, the patient agreed to an admission after a near fatal overdose on fentanyl that required revival with Narcan. She has been in a relapse for the past 30 days after 4.5 years of abstinence. The patient was in a 12-step program when she relapsed. The patient required 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 as a less intensive level of care. For dimension 5, the patient has been in a relapse of using daily intravenous fentanyl for one month after a 4.5 year period of abstinence after her last RTC stay. The patient overdosed on 8/1/20 and she is continued to have urges to use. She relapsed despite participation in her 12-step group with sponsor. Despite recent active participation in treatment at less intensive level of care, the patient continued to use drugs with imminent serious consequences and was at high risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patients social network consists of mostly substance users. Her boyfriend is in rehabilitation for alcohol use and they have engaged in physical altercations. Her family is unaware of her substance use problem. She was noted to be easily agitated and struggling with decision-making around her dysfunctional relationships. The patient has been unable to cope, for even limited periods of time, outside of 24-hour care. She needs staff monitoring to learn to cope with dimension 6 problems before being transferred to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for RTC level of care. Therefore, the RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.