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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria this patient meets 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 underwent withdrawal management for benzodiazepine  withdrawal earlier in his treatment stay. The patients withdrawal needs can be safely managed in Level 3.5 setting.For dimension 2, the patient has history of withdrawal seizures and prior infection secondary to IV drug use requiring peripheral intravenous catheter placement. The patients biomedical problems, if any, are stable, and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with PTSD and depressive disorder. The patient endorsed using IV heroin or fentanyl for several years. The patient overdosed in July 2021, which required treatment with Narcan and emergency room services. The patient has encountered legal consequences due to his substance use disorder with subsequent relapse. The patient also smuggled fentanyl and other substances into the facility. The patients mental status has been assessed as sufficiently stale to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has demonstrated a 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. For dimension 4, the patient was voluntarily admitted for treatment due to his girlfriend, who is also addicted to fentanyl, being pregnant with his child. The patient has been using heroin and fentanyl for the past nine years and he has significant legal problems. The patient has not been able to find work over the past three years due to his drug usage and criminal record. The patient blames his ongoing drug usage on this issue as he becomes discouraged about his life changing. The patient is preoccupied with this pregnant girlfriends ongoing drug usage rather than on his own treatment. He has been unable to maintain abstinence in the community and had multiple relapses despite legal, relationship, and financial consequences. The records document that the patients perspective impairs his ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable him to develop insight into the role he plays in his substance use and empower him to make behavioral changes which can only be delivered in a 24-hour milieu. For dimension 5, the patient was started on suboxone during this treatment stay. The records suggest that the patient has not followed through with medication assisted treatment after discharge. The patient reports that he has ongoing cravings and urges to use opiates. The patient has been using IV fentanyl combined with Xanax to the point of blackouts and overdose requiring Narcan and emergency room stay in July 2021. The patient is experiencing addiction symptoms such as drug craving. This 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. For dimension 6, the patient has been living with his pregnant girlfriend who is addicted to heroin. The patient has been unemployed for the past three years. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the RTC services (ASAM 3.5) 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 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.