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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC), equivalent to ASAM 3.5, provided by The Lakes Treatment Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC services from 4/19/22 forward. 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 management for opioid and benzodiazepine withdrawal earlier in her treatment stay. The patients withdrawal needs were and are safely managed in a Level 3.5 setting. For dimension 2, the patient has chronic pain from fibromyalgia that affects her ability to fully participate in treatment. The patients biomedical problems, if any, are stable. For dimension 3, the patient has diagnoses of generalized anxiety disorder, depressive disorder, and fibromyalgia. She continues to report a high level of craving to use substances. She has a history of overdose requiring Narcan and has a history of three driving under the influence (DUI) charges, including one DUI that resulted in injury to another person. She reports using substance while working, passing out on top of the client she was working on.  The patients mental status is stable enough to permit participation, she demonstrates a repeated inability to control her impulses to use alcohol and other substances, and she 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 admitted for treatment at the request of her family as she was stealing her aunts Xanax and Soma. Her family is no longer allowing her to return to live at their home. The patient had previously attended three weeks of an intensive outpatient program (IOP) but reported using substances while participating in the program and subsequently overdosed. The patient required 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. For dimension 5, the patient reported using substances during her first attempt at treatment in an IOP. She subsequently overdosed, requiring Narcan. Despite recent, active, participation in treatment at a less intensive level of care the patient continued to use drugs with imminent serious consequences and was at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient was living with her aunt, who takes Xanax and Soma, prior to being admitted to the RTC. She was caught stealing her aunts Xanax and Soma and was told that she would not be allowed to return to live with the family. She has a pending DUI court case. She is socially isolated. The patients social network living with an individual who is a regular user of drugs. Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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, RTC, equivalent to ASAM 3.5, provided by The Lakes Treatment Center 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 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.