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 3.1 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 continued to report withdrawal symptoms including irritability, bone pain, and stomach cramps. She was restarted on suboxone and received her first dose of Sublocade a few weeks later. The patients withdrawal needs can be met in Level 3.1 setting. For dimension 2, the patient has no reported medical problems. The patients biomedical problems were stable and did not require medical or nurse monitoring. For dimension 3, the patient was diagnosed with major depressive disorder, recurrent, generalized anxiety disorder, and trauma-related disorder. She has experienced significant problems with depression and anxiety and was using substances to manage these symptoms. She actively participated in groups but struggled with focusing. The patients mental status was stable to permit participation in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients symptoms and functional limitations, when considered in the context of her home environment, were sufficiently severe that she was assessed as not likely to maintain abstinence if treatment was provided in a nonresidential setting. For dimension 4, the patient voluntarily admitted herself due to worsening consequences of her uncontrolled substance usage including legal, relationship, and parenting problems. She was motivated to complete the program. The patient acknowledged the existence of a substance use problem. She recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient was using heroin, intravenous methamphetamine, and alcohol heavily for the past two years. She used substances in a maladaptive manner in order to cope with the stressors in her life. The patient understood her addiction and mental disorder but was at risk of relapse in a less structured level of care because she was unable to consistently address either or both. For dimension 6, the patient was living with her boyfriend and children in a unit attached to her parents property. Her parents drink alcohol and her social network is comprised of drug dealers and drug users. The patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment made recovery unlikely and the patient had insufficient skills to maintain adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the 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 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.