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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met 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. The patient underwent withdrawal management for opioid withdrawal and had consistently high Clinical Opiate Withdrawal Scale (COWS) scores of 17-22, elevated pulse, and agitation. Based on clinical findings, the patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patients medical history was limited to hepatitis C and that he did not have any ongoing medical problems. The patients biomedical problems were therefore stable and did not require medical or nurse monitoring.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient had schizoaffective disorder, depressive type, and he had been hearing voices that were derogatory and distressing. He eloped from the facility 1 to 3 times per day in order to run away from these voices. Notes indicate that he was impulsive and had an episode of physical aggression towards property. He did participate in groups. The patient met the subcriteria of having mental status that was stable enough to permit participation. At the same time, the patient demonstrated a repeated inability to control his impulses to use drugs or to engage in antisocial behavior and was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction was of such severity that it precluded participation in treatment in the absence of the 24-hour support and structure of a level 3.5 program.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily with his mother's assistance because he was tired of using drugs and the resultant consequences of homelessness. He had been using as much heroin and methamphetamine daily as he could obtain during the prior seven years. He had significant psychiatric instability during his treatment and was evidently hearing distressing voices that he managed by running off the property. He demonstrated poor insight into his substance use and psychiatric symptoms and did not regularly adhere to recommended medications for either problem. Therefore, because of the intensity and chronicity of his addictive disorder and his mental health problems, the patient had limited insight and little awareness of his need for continuing care and treatment, and he had limited readiness to change.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient had been using heroin and methamphetamine daily since the age of 20. He previously relapsed after 18 months of sobriety. He was incarcerated for 6 months earlier in the year. He was actively psychotic during his treatment stay with urges to use and consistent eloping behaviors. He had extremely low frustration tolerance around others and had anger outbursts over recommended medications at the facility. The patient did not recognize his relapse triggers and he lacked insight into the benefits of continuing care and was therefore not committed to treatment. His continued substance use posed an imminent danger of harm to himself or others in the absence of 24-hour monitoring and structured support.For dimension 6 - Recovery Environment. The patient had been living in his car for the past five years. He was unemployed and his only support was his mother. He was previously incarcerated for six months earlier in the year. The patient was unable to cope with the voices and agitation in the facility without running away 1 to 3 times each day. Thus, the patient was unable to cope, for even limited periods, outside of 24-hour care. He needed staff monitoring to learn to cope with problems before he could be safely transferred to a less intensive setting.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 services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's 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.