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, specifically ASAM Level 3.5. 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 has not experienced any withdrawal issues of concern. The patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient reportedly is being evaluated for syphilis. She also has a history of bursitis of her hip and blindness in one eye. The patients biomedical problems, if any, have been 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 methamphetamine use disorder and cannabis use disorder. The patient has been smoking methamphetamine multiple times daily since she relapsed. She has been using despite losing custody of her children due to an extensive history of abuse and neglect. The patient has demonstrated ongoing difficulty with delaying gratification and impulse control due to her chronic addictive disorder. The patient continues to be emotionally neglectful to one of her children with whom she has tried to sever parental rights, indicating a severe level of dysfunction and potential for harm to others. The provider noted that the patient has participated in groups. The patients mental status has been assessed as sufficiently stable to permit participation in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient demonstrates repeated inability to control her impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, and property. The resulting level of dysfunction is so severe that it precludes the patients participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted voluntarily due to severe consequences of her addiction to methamphetamine including losing custody of her children and criminal charges. This is the patients second attempt at treatment. She is in precontemplative stage of change. She has failed to take full responsibility for her role in her situation. The patient has tried to give up her parental rights to one child due to the childs behavior problems. The patient demonstrates antisocial behavior patterns that have led to significant criminal justice problems, lack of concern for others, and extreme lack of regard for authority, which prevents movement toward positive change and precludes participation in a less structured and intensive level of care. Despite experiencing serious consequences or effects of the addictive disorder or mental health problem, the patient has marked difficulty in understanding the relationship between her substance use, addiction, mental health, or life problems and her impaired coping skills and level of functioning, often blaming others for her addiction problems. For dimension 5, the patient has been using methamphetamine multiple times daily since relapsing after a five-year period of sobriety. The patient is seeking treatment due to having her children removed from her home and the prospect of losing her parental rights. The patient has been involved in criminal activities. The patient does not recognize specific relapse triggers. She has been physically and emotionally abusive to her children. She has continued to engage in severe emotional abuse of one child through text messages by communicating that she wants to disown the child. 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 danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient lives with her boyfriend who also uses substances. The patients home has been raided multiple times due to illegal activity. The patient has lost her children due to her methamphetamine use. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as unachievable 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 for substance abuse disorder, 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.