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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for all or any of the residential treatment center (RTC) (ASAM 3.5) level of care for a specific time period. At issue is whether all or any of the residential treatment center (RTC) (ASAM 3.5) level of care for a specific time period was medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A). Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC level of care for the specific time period requested.For dimension 1, the patient underwent withdrawal management for opioid withdrawal and had Suboxone dosage adjusted throughout their treatment stay. Based on clinical findings, the patients withdrawal needs could have been safely managed in a Level 3.5 setting.For dimension 2, the patient has a history of drug-induced seizures and chronic pain. The patients biomedical problems were stable.For dimension 3, the patient has been diagnosed with anxiety disorder. The patient has been using 70 mg of OxyContin on a daily basis for the past several months. The patient has attempted to detox and quit OxyContin. The patient has continued to have cravings, uncontrollable anger, and extreme irritability. The patient has participated in groups. Based on these findings, the patient met the requirements for this dimension.For dimension 4, the patient was admitted voluntarily for treatment after being unable to stop using OxyContin on their own. The patient has been using opiates problematically for two years. The patient previously did a partial hospitalization program and then relapsed after six months. They went on to have drug-induced grand mal seizures after overdosing on kratom on two occasions and then continued using. They struggled with participation in the treatment and was noted to be apathetic and disinterested. Based on these findings, the patient met the requirements for this dimension.For dimension 5, the patient was started on Suboxone for the first time, but they continued to have ongoing cravings, irritability, and agitation. Their dosage was being adjusted during the RTC treatment period. Based on these findings, the patient met the requirements for this dimension.For dimension 6, the patient has not been able to cope without using substances outside of detox except for a six-month period. The patient has been unable to work due to their addiction.  They have been relapsing for months and was using in their home environment. Based on these findings, the patient met the requirements for this dimension.The ASAM criteria requires adult patients to meet all six dimensions to support residential treatment center services. This patient did meet all the dimensions for Level 3.5 residential treatment center criteria. Moreover, the services were in accordance with the generally accepted standards of mental health and substance use disorder care. Given these findings, the RTC (ASAM 3.5) level of care for a specific period of time was 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 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.