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 (ASAM Level 3.5 RTC) services. Per 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 underwent withdrawal management for opioid and alcohol withdrawal at a different facility prior to this admission. The records noted continued symptoms of withdrawal including anxiety, restlessness, and night sweats. The patients withdrawal needs are safely managed in a Level 3.5 setting. For dimension 2, the patient has hepatitis C, without active medical problems. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring. For dimension 3, the patient has diagnoses of generalized anxiety disorder and severe major depression. He endorsed frequent suicidal thoughts over the past several years without active intent. The records noted continued severe cravings, anxiety, and depression.  The patient was willing to start psychotropic medications for depression and was initially willing to undergo medication-assisted treatment (MAT) but ultimately discharged against clinical advice.  The records noted a history of over 20 overdoses, with up to four occasions requiring medical hospitalization. The patients mental status was stable enough to permit participation, he demonstrated a repeated inability to control his impulses to use substances or alcohol, and he was in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction is so severe that it precludes the patient's participation in a less structured and intensive level of care.For dimension 4, the patient was admitted voluntarily for treatment following an eight-day withdrawal management treatment stay at a different facility.  He had declined to participate in a suboxone aftercare program following his detoxification and reported being homeless for two to three days following discharge from detoxification. The patient appeared ambivalent and varying in his level of participation and engagement. He had a history of over twenty overdoses. The patient demonstrates passive or active opposition to addressing the severity of his mental health illness or addiction or does not recognize the need for treatment.  Such continued substance use or inability to follow through with mental health treatment poses a risk of danger to harm or others. However, assessment indicates that treatment interventions available at Level 3.5 may increase the patient's degree of readiness to change.For dimension 5, the patient has a long history of opioid and alcohol use disorder and multiple attempts at residential treatment and relapses. He has poor insight into his relapse triggers and need for treatment, including MAT. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. His continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient moved to California from Tennessee four years ago and reported having little contact with his family since. The patient is homeless, unemployed, and does not have any sober supports in California. The patients social network includes regular users of drugs such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM criteria for RTC services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the RTC (ASAM Level 3.5 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 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.