Appeal type: Medical Necessity
Decision: Overturned

Standard Review Fulfills requirements of (1374.33) (h)(1)(A, B, C, D, G, H, I, K)Age: 44Gender: MNature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the adult substance use disorder inpatient detoxification services provided at The Betty Ford Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for inpatient detoxification 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 was placed on a suboxone taper and lorazepam taper for opioid withdrawal. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient had severe back pain that following six back surgeries within four years that was managed with a high dosage of opioids. He required medically managed detoxification and optimization of pain management without narcotics. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported suicidal ideation prior to admission for treatment, and difficulty tolerating his chronic back pain without resorting to abusing opioids. The patient reported taking high dosages of opioids with escalating use over the past four years and through insufflation. The patients mental status was stable enough to permit participation, and he demonstrated significant functional deficits, which when considered in the context of his home environment, were sufficiently severe that he was unlikely to maintain mental stability or abstinence in a non-residential setting.For dimension 4, the patient voluntarily admitted himself for treatment but initially misreported  the amount and methods by which he was using substances. He reported that he feared losing his professional license over his substance use and attributed his usage and abuse of opioids to his back pain. This was his first attempt at treatment. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because he had limited insight and awareness due to the intensity and chronicity of his addictive disorder.For dimension 5, the patient reported using prescription opioids and fentanyl patches for the past four years. He had been unable to reduce his usage due to withdrawal symptoms and uncontrolled back pain. This was his first attempt at treatment. The patient was assessed as being at high risk for relapse due to a lack of insight on how to manage his back pain, a relapse trigger, without resorting to opioids. Despite his best efforts, the patient was unable to control his use of drugs with attendant probability of harm to self in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient was single and on long-term disability due to his chronic back pain. He lived with a roommate and did not have a sober support system. He had severe back pain that he only knew to manage with opioids. The patient was unable to cope, for even limited periods of time, outside of 24-hour care.Given these findings, the patient met the six ASAM criteria for adult substance use disorder inpatient detoxification services provided at The Betty Ford Center. Accordingly, adult substance use disorder inpatient detoxification services provided at The Betty Ford Center were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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.