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 patient had been using inhalants and prn Xanax. She was monitored and treated with a Librium taper. The patients withdrawal needs could have been met in Level 3.5 setting. For dimension 2, the patient had COVID-19 during her treatment stay but was medically stable during his admission. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient was diagnosed with bipolar mood disorder at age 17. She has been in a prolonged depressive episode. She was sober from alcohol for two years, which she replaced with inhalants, with usage escalating to eight cans multiple times per week. She reports having tried to quit using on her own multiple times without any success. She indicated that she has blacked out in public, experienced seizures, and sustained a head injury due to alcohol use. She has been placed on three 5150 holds over the past eight months for overdoses. 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. The patient demonstrated repeated inability to control her impulses to use alcohol and other drugs and was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction was of such severity that it precluded participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient admitted herself voluntarily after she experienced a blackout from huffing that resulted in her falling and hitting her head. She reported a desire to stop using. She has tried to stop on her own and this was her first attempt at residential treatment. Due to her inhalant use, she has been unemployed and living with her parents. She has sustained multiple blackouts, injuries, and seizures as a result of her huffing usage. She has also been in prolonged depressive episode and has difficulty understanding the role of the inhalant usage into her depressive symptoms. Despite experiencing serious consequences of the addictive disorder, the patient had marked difficulty in understanding the relationship between her substance use, mental health, or life problems and her impaired coping skills and level of functioning. For dimension 5, the patient has not experienced any period of abstinence from inhalant use. She endorsed a high level of craving while in the RTC. She continued to be depressed and was noted to have difficulty with social interactions and with participation in the facility. When using she places herself at risk by huffing to the point that she blacks out and falls or has seizures. She continued to report that she was not sure if she was ready to quit using. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment. Her continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient is living with her parents and unemployed. She is socially isolated as she moved to a different city when she needed to move back in with her parents. She does not have any friends in the local area. She has been unable to control her usage despite repeated blackouts and other negative consequences of huffing. The patient was unable to cope, for even limited periods of time, outside of 24-hour care. She needed staff monitoring to learn to cope with Dimension 6 problems before being transferred to a less intensive setting. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC level of care 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.