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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services, and authorization and coverage for trazodone. The Health Plan has denied this request indicating that the services and medication at issue were not and are not medically necessary for treatment of the enrollees behavioral health issues.   The records provided for review support the medical necessity of the RTC services, and treatment with trazodone, for management of this patients behavioral health issues. The American Society of Addiction Medicine (ASAM) has established a series of six dimensions to create a holistic, biopsychosocial assessment of an individual to be used for service planning and treatment across all services and levels of care. The six dimensions are:Dimension 1: Acute intoxication and/or withdrawal potentialDimension 2: Biomedical conditions and complicationsDimension 3: Emotional, behavioral, or cognitive conditions and complicationsDimension 4: Readiness to changeDimension 5: Relapse, continued use or continued problem potentialDimension 6: Recovery/living environmentASAM criteria further state that adolescents can be appropriately placed at an RTC level facility when at least two of the above dimensions have been met.Here, the patient has met Dimensions 3-5. The patient meets Dimension 3 because he has a number of emotional/behavioral conditions. Dimension 4 has been met because the patient has not yet demonstrated any motivation to change. Dimension 5 has been met because the patient lacks recognition of relapse triggers. Since more than two Dimensions have been met for this adolescent patient, ASAM criteria for RTC level of care have been satisfied.With regard to the request for trazodone, literature indicates that insomnia is a common symptom of substance withdrawal, even months after last use. Evidence supports the use of trazodone in adolescents when the patient has a comorbid mood disorder. In this case, the patient continues to have insomnia issues as well as mood issues. The patient likely has a mood disorder and insomnia due to withdrawal from substances. Thus, trazodone is medically necessary given the available evidence supporting its use in this clinical setting. Accordingly, the RTC services and the request for trazodone were and are medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services and medication 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 with expertise in child and adolescent 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. In addition, the reviewer holds a current certification by a recognized American medical specialty board in the area or areas appropriate to the treatment under review.