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

An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.5 criteria for the residential treatment center services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. When he began receiving services, the patient still had mild to moderate opioid withdrawal symptoms of anxiety, agitation, irritability, aches, and tachycardia with Clinical Opiate Withdrawal Scale (COWS) scores ranging from 4 to 12. Under these circumstances, the patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient did not report any medical conditions. Therefore, the patients biomedical problems were stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient had complaints of anxiety and depression. He reported significant gambling prior to relapse. He was also noted to be very impulsive and had trouble with immediate gratification. He was noted to have problems with anger and aggression, and he had three felony assault charges including threats and assault with a deadly weapon. The patient was on probation for assault with a deadly weapon and was wearing an ankle bracelet. He had several instances of breaking the rules and then lying about it while at the facility. The patient participated in groups but was noted to be guarded and irritable. While the patients mental status permitted participation, he demonstrated antisocial behavior patterns (as evidenced by criminal activity) that led to significant criminal justice problems and which prevented movement toward positive change and precluded participation in a less structured and intensive level of care.For dimension 4 - Readiness to Change. The patient presented for treatment as he relapsed after a year and a half of sobriety. He had been using cannabis since the age of 13 and heroin since the age of 16. He has been using 2 grams of heroin intravenously daily since his last relapse. He made several statements about leaving the residential treatment center early and abruptly while he was there. He had serious consequences of his drug usage including serious legal problems, financial problems, and an inability to work due to the severity of his addiction. Because of the intensity and chronicity of the patients addictive disorder, he had limited insight and little awareness of his need for continuing care, and thus had limited readiness to change.For dimension 5 - Relapse, Continued use, Continued Use, or Continued Problem Potential. The period of residential treatment center services under consideration was the patient's second attempt at treatment, after relapse following 18 months of sobriety. The patient relapsed after his girlfriend relapsed and was using in front of him. He and his girlfriend were still living together and she was reported to be trying to get into treatment. The patient was not receiving any treatment or doing 12 step groups. He was transitioned from buprenorphine detox to naltrexone to reduce his cravings. The patient was experiencing addiction symptoms such as drug craving and insufficient ability to postpone immediate gratification. Under these circumstances, the introduction of psychopharmacologic support was indicated to decrease the patients addictive symptoms.For dimension 6 - Recovery Environment. The patient had been living with his girlfriend, who was also using heroin. He was noted to have been stealing to support his habit, and had related legal charges. The patients social network therefore involved living with an individual who was an addicted user.Using the ASAM level 3.5 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.5 treatment. Accordingly, the residential treatment center (RTC) services at issue were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.