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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for substance abuse inpatient hospitalization services (ASAM Level 4.0). Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 4.0 criteria for substance abuse inpatient hospitalization 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 ASAM Level 4.0 services, the patient must meet criteria in at least one of Dimensions 1, 2, or 3. Dimensions 4, 5 and 6 are not considered for this level of care so an analysis of these dimensions is not pertinent for this review. For dimension 1, the patient was treated for opioid withdrawal with suboxone and other medications. The patients Clinical Opiate Withdrawal Score (COWS) scores were from 0-4. He did not have any evidence of severe or unstable withdrawal with need for 24-hour nursing care and daily physician visits to modify withdrawal management regimen and manage medical instability. Based on clinical findings the patient did not meet the requirements for this dimension. For dimension 2, the patient has asthma that is well controlled. He did not have any biomedical complications of his addictive disorder requiring medical management or skilled nursing care, or concurrent biomedical problems that required medical or nurse monitoring. There is a lack of support that with continued drug use there would have been an imminent danger to life or health, recurrent seizures, life-threatening symptoms related to use of opioids, or opioid use complicating a previously diagnosed medical condition. Based on clinical findings the patient did not meet the requirements for this dimension.For dimension 3, the patient did not have psychiatric complaints. The records do not support a psychiatric diagnosis. The patient was not suicidal or homicidal. He did not have any emotional, behavioral, or cognitive complications of his addictive disorder. He did not have uncontrolled behaviors posing an imminent danger to self or others, mental confusion or fluctuating orientation extreme depression, impairment of thought processes, or altered mental status. Based on clinical findings the patient did not meet the requirements for this dimension.Given these findings, this patient did not meet the criteria for ASAM Level 4.0 dimensions 1, 2, or 3. For these reasons, the substance abuse inpatient hospitalization services (ASAM Level 4.0) were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.