Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) (ASAM Level 3.5) services provided at Rocky Mountain Treatment Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient met 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 was monitored for withdrawal symptoms and reported anxiety and insomnia. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient did not have biomedical problems and did not require 24-hour medical or nurse monitoring. For dimension 3, the records noted that the patient had symptoms of depression and anxiety. The patient had a history of overdoses, both intentional and unintentional, and a suicide attempt the year prior via overdose. He was unable to control his impulses to use substances prior to RTC admission despite moving out of California. The patients mental status was stable enough to permit participation, he demonstrated a repeated inability to control his impulses to use substances, and he was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient was admitted voluntarily for treatment. He reported taking up to 20 mg of Xanax daily, 1 gm to 3.5 gm of cocaine daily, and drinking up to 15 beers and 15 shots most days for the past two years. The records noted that he did not have coping skills to cope with stressors, was resistant to the concept of total abstinence, and wanted to leave the RTC. The patient required structured therapy and a 24-hour programmatic milieu because he had limited insight and awareness of the need for continuing care or the existence of his substance use and need for treatment due to the intensity and chronicity of the addictive disorder, and thus had limited readiness to change. For dimension 5, the patient reported taking up to 20 mg of Xanax daily, 1 gm to 3.5 gm of cocaine daily, and drinking up to 15 beers and 15 shots most days for the past two years. He had a history of overdoses, both intentional and unintentional, and a suicide attempt. He had poor insight into his substance use problem and was unable to identify relapse triggers. He reported wanting to leave the RTC and was noted to be passively opposed to treatment. The patient did not recognize relapse triggers and 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 self or others in the absence of close 24-hour monitoring and structured support.For dimension 6, the patient moved to Montana a short time prior to his admission to the RTC, was unemployed, homeless, and living in a friends car. The patient was unable to cope, for even limited periods of time, outside of 24-hour care and required staff monitoring to learn to cope with problems before being transferred safely to a less intensive setting.Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, the RTC (ASAM Level 3.5) services provided at Rocky Mountain Treatment 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.