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

The patient has requested reimbursement and prospective authorization and coverage for Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 patients withdrawal needs can be safely managed in a Level 3.5 setting. The patient was started on buprenorphine 24 mg daily as a taper protocol from opiates and on a Librium taper given her heavy alcohol use. She continued to experience protracted withdrawal with symptoms including agitation, anxiety, headache, paroxysmal sweats, and tremors. For dimension 2, the patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. During the taper period, the providers noted that it was imperative for them to observe the patient dissolving the buprenorphine strip under her tongue and they noted compliance. For dimension 3, the patients mental status is assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient endorsed engaging in antisocial behavior including driving under the influence and risky sexual behaviors while using substances. The patient reportedly accidentally overdosed on at least one occasion, which required Narcan reversal. The patient has demonstrated repeated inability to control her impulses to use alcohol and other drugs and to engage in antisocial behavior, and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of the 24-hour support and structure of this Level 3.5 program. For dimension 4, despite experiencing serious consequences of the addictive disorder, the patient has marked difficulty in understanding the relationship between her substance use, addiction, mental health, and life problems and her impaired coping skills and level of functioning, often blaming others and external circumstances for her addiction problems. The patient continues to struggle with co-dependency and significant guilt over her brothers death, as well as feelings of shame and anxiety. She has symptoms of post-traumatic stress disorder (PTSD) from the multiple traumas she has experienced in the context of her substance use disorder.  She is struggling with a buprenorphine taper with continued protracted withdrawal symptoms in anticipation of Vivitrol induction. For dimension 5, the patient is experiencing psychiatric symptoms of anxiety, anger, shame, inability to focus, and drug craving, and has insufficient ability to postpone immediate gratification and other drug-seeking behaviors. This situation poses an imminent danger to herself in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support has been indicated to decrease psychiatric or addictive symptoms, such as cravings, that will enable to patient to delay immediate gratification and reinforce positive recovery behaviors. The patient has a history of accidental overdose that required Narcan reversal. Her risk of overdose is further elevated since she is tapering off buprenorphine. She was initially resistant to try medication for her anxiety, but eventually agreed. She has benefited from the close 24-hour monitoring provided and structured environment at this level of care. For dimension 6, the patient has been unable to cope, for even limited periods of time, outside of 24-hour care. She needs staff monitoring to cope with her Dimension 6 problems before being transferred safely to a less intensive setting. Prior to admission, the patient was unemployed and living in a trailer on her parents land. She is in a co-dependent relationship. The provider noted that the patients judgment remains poor to fair, her mood is labile, and she is struggling with anxiety and feeling shaky. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the dual diagnosis RTC services were and are 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.