Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. 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 patient underwent withdrawal management earlier in her treatment stay. The patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient has history of congenital hyperinsulinism. 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. For dimension 3, the patient has been diagnosed with amphetamine use disorder and cannabis use disorder. She has been using meth on a daily basis for the past five years and her son has been removed from her custody. She has significant history of childhood sexual and physical abuse that has led to functional impairment. She has been inappropriately hypersexual and provocative during her treatment stay. The provider also noted that the patient is attention-seeking with several instances of breaking the rules. She has participated in groups. The patients mental status has been 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. In addition, the patient has significant functional deficits, which are likely to respond to staff interventions. These symptoms and deficits, when considered in the context of her home environment, are sufficiently severe that the patient is not likely to maintain abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus; they do not require medical monitoring or management. They may include chronic addictive disorder and the sequelae of physical, sexual, or emotional trauma. For dimension 4, the patient was admitted to RTC voluntarily after leaving an abusive relationship with the father of her child. The patients child has been removed from her custody due to her methamphetamine use. The patient is currently homeless. She has relapsed immediately after discharge from RTC, and she has no history of following through with outpatient services. The patient requires structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care and such interventions are assessed as not likely to succeed at a less intensive level of care. For dimension 5, the patient endorsing using 14 gram of methamphetamine daily for the past five years. She has undergone three prior attempts at treatment and her longest period of sobriety has been 37 days while she was in RTC. She is currently homeless. The patient reported that her boyfriend has contacted her at the RTC and threatened show up with firearms. The patient is in imminent danger of relapse, with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. Her continued substance use poses an imminent risk of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient is currently homeless after leaving an abusive relationship with the father of her child. She does not have any friends or social support system. The patient has been living in an environment that is characterized by a moderately high risk of neglect with repetition of physical, sexual, or emotional abuse, or substance use so endemic, that the patient is assessed as being unable to achieve or maintain recovery at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the RTC services, specifically ASAM level 3.5, 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. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine 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.