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

Nature of Statutory Criteria/Case Summary: The patient is a male with cannabis use disorder, opioid use disorder, hallucinogen use disorder, generalized anxiety disorder, parent-child relational problem, and sedative, hypnotic, or anxiolytic use disorder. The patient overdosed and had been in therapy since that time. He was admitted to a residential treatment center (RTC). The patient was noted to have difficulties within the family setting and did not feel it was a safe environment for his recovery. The patient was reported to be able to process information and take accountability faster than on admission. The patient was able to improve communication with his parents. The patient reported feeling motivated and recognized growth in his ability to socialize without substances. The parent of the patient requested reimbursement for RTC level of services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether the RTC level of care services were medically necessary. The American Society of Addiction Medicine (ASAM) criteria is a comprehensive set of guidelines for placement, continued stay, transfer, and discharge of patients with addiction and co-occurring conditions. According to these criteria, an adolescent who is appropriately placed in a RTC level program meets specifications in at least two of the six dimensions. These dimensions include: acute intoxication; biomedical conditions; emotional, behavioral, cognitive conditions; readiness to change; relapse, continued use, or continued problem potential; and recovery environment. This patients records indicate there was no evidence of acute intoxication or biomedical conditions. The records noted improvement in emotional, behavioral, and cognitive conditions, as the patient was better able to process information and take accountability for his actions. The patients readiness to change had increased and an improvement in his family relationship was noted. A change in family interactions demonstrated improvements in the recovery environment. The patient and his parents made a home contract, which they felt was supportive and would allow the patient and family to succeed. The patient recognized growth in his ability to socialize without substances and feel confident. He reported feeling motivated in his recovery and was planning on spending more time with his sponsor after discharge. The records did not indicate that the patient met specifications of at least two of the six ASAM dimensions. Therefore, RTC level of care was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with a subspecialty 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.