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

An enrollee has requested reimbursement and authorization and coverage for Dual Diagnosis Residential Treatment Center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.5 criteria for residential treatment center services. ASAM criteria focus on six dimensions to determine the appropriate level of care. For dimension 1, detoxification/withdrawal potential, the patient continued to have mild to moderate withdrawal symptoms with Clinical Opiate Withdrawal Scale (COWS) scores ranging from 7-10 and Clinical Institute Withdrawal Assessment (CIWA) scores ranging from 10-12. He was managed for withdrawal with a Librium taper and was maintained on Suboxone. The patients withdrawal needs could be safely managed in this setting. For dimension 2, biomedical conditions and complications, the patient did not have any biomedical problems that were not stable or that required 24-hour medical monitoring. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patient was diagnosed with major depressive disorder and generalized anxiety disorder, and he was felt to have underlying personality disorder. The patient continued to complain of anxiety, depression, anhedonia, irritability, and was noted to have impulsive and self-sabotaging behaviors as well as antisocial behavior patterns of stealing from others to support his habit and selling drugs. The patients mental status permits participation. In addition, the patient demonstrates antisocial behavior patterns that could lead to significant criminal justice problems and that preclude participation in a less structured and intensive level of care. For dimension 4, readiness to change, the patient has been using fentanyl and methamphetamine heavily. He has left prior treatment before completing it. The patient also relapsed immediately after release on his last treatment center attempt. In this case, because of the intensity and chronicity of the patients addictive disorder, he has limited insight and thus has limited readiness to change. For dimension 5, relapse, continued use, or continued problem potential, the patient has had at least four prior attempts at treatment in the past three years. He left one program before completing it, and most recently relapsed immediately after release from another program. The patient has ongoing cravings to use, and he was previously using a large amount of fentanyl IV on a daily basis. He was started on Suboxone while in the facility. He is also noted to be impulsive. The patient is therefore experiencing drug craving and in this situation poses an imminent danger of harm to himself in the absence of close 24-hour monitoring and structured support. For dimension 6, recovery/living environment, the patient lives at home with his mother and father. His social network consists of other drug users and dealers. He has been stealing and selling property to maintain his habit and has also been dealing drugs. The patients social network therefore includes regular users of drugs such that his recovery goals would be unachievable at a lower level of care. Using the ASAM level 3.5 criteria worksheet, the patient meets all six criteria for medical necessity and therefore qualifies for ASAM Level 3.5 treatment. Accordingly, the requested Dual Diagnosis Residential Treatment Center (RTC) services at issue and requested services were, and are, medically necessary for the patients medical condition.Final Result: The reviewer determined that the services in issue and requested services were, and are, medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.