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 any or all of the RTC level of care. 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 management for opioid and sedative-hypnotic withdrawal. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had a diagnosis of hepatitis C. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring.  For dimension 3, the patient was diagnosed with depression and attention deficit hyperactivity disorder (ADHD). The patient was not compliant with following up on mental health treatment and had a long history of severe amphetamine and opioid use disorder. The records noted ongoing difficulty with impulse control and five heroin overdoses in the 30 days prior to admission, requiring hospitalization twice. The patients mental status was stable enough to permit participation, he demonstrated a repeated inability to control his impulses to use substances, and he was in imminent danger of relapse with attendant likelihood of harm to self  in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted himself voluntarily for treatment. He reported using heroin intravenously, along with methamphetamine. He had previously undergone medication-assisted treatment (MAT) twice with Sublocade but was noncompliant with subsequent monthly injections and continued using substances despite being in the outpatient MAT program. 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 relapsed despite being in a MAT outpatient program. He continued to use substances, with five overdoses within the 30 days prior to admission to the RTC. 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 is single. He reported selling drugs and being unemployed. He did not have sober friends and lacked a sober support network. 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 met the six ASAM criteria for RTC level of care. 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 level of care was and is 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.