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. 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 patients withdrawal needs can be safely managed in Level 3.5 setting. The patient was managed for opioid and benzodiazepine withdrawal with suboxone and diazepam taper. He required additional medications of clonidine and baclofen for withdrawal management. For dimension 2, the patients biomedical problems are stable, and do not require 24-hour medical or nurse monitoring. The patient has medical conditions of Crohns disease and chronic pain due to several orthopedic injuries. His ongoing pain management issues complicate and exacerbate his urges to use opioids. For dimension 3, the patient has complaints of anxiety and depression. He has been using substances including opioids and benzodiazepines to manage his emotions. He has also been using benzodiazepines and opioids despite being in treatment for suboxone which demonstrates an inability to control his impulses. The patients mental status permits participation. The patient demonstrates repeated inability to control his impulses to use substances and engaged in antisocial behavior. The patient exhibits antisocial behavior patterns as evidenced by significant criminal justice problems, which prevents movement toward positive change and precludes participation in a less structured and intensive level of care. For dimension 4, requires 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 at a less intensive of care. The patient presented for treatment at the recommendation of his provider as he continued to relapse on opiates and benzodiazepines despite being in suboxone treatment for the past year. He had previously been in an IOP but continued to drink during treatment. He has experienced serious consequences of his concomitant use of benzodiazepines, oxycodone, alcohol and suboxone, which place him at high risk for overdose. For dimension 5, the patient remains at elevated risk for relapse. This is the patients first attempt at RTC level of care after relapse in January 2020 after eight months of abstinence from oxycodone. He relapsed on oxycodone, lorazepam and continues to use alcohol despite being prescribed suboxone and participating in outpatient psychosocial treatments. Despite recent, active participation in treatment at a less intensive level of care, the patient continues to use drugs with imminent serious consequences and is 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 involves living with an individual who is a regular user or addicted user of alcohol or other drugs, that his recovery goals are assessed as unachievable. The patient has been living with his girlfriend who is a regular user of alcohol. Given these findings, the patient meets the six ASAM dimensions for RTC services. Thus, the RTC services provided at Olympia House Rehabilitation (Sonoma Recovery Services) 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.