Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for substance abuse residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria this patient meets Level 3.5 criteria for RTC services, but the duration of treatment is determined by the patients progress in meeting treatment plan goals rather than a predetermined number of days. 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 would need to have withdrawal management or detoxification services during his initial phase of treatment. The patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient does not have active medical problems. 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 opioid use disorder and he also regularly uses Xanax and methamphetamine. The patient endorsed smoking 1.5 grams of heroin daily for three years, smoking methamphetamine several times per week, and mixing Xanax with the heroin. The patient has experienced blackouts due to his substance abuse. The patient reports feeling suicidal on a regular basis. The patient ongoing difficulty with delaying gratification and impulse control due to his addictive disorder. The patient was discharged from RTC after being caught trying to sell substances and he shoplifted from a local store. He did participate in groups while at the RTC. The patient has been using heroin several times a day and he has been unable to stop due to withdrawal symptoms. 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. The patient demonstrates repeated inability to control his 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 is in the contemplative stage of change since he has made attempts to achieve abstinence through participation in a chemical dependency rehabilitation program and then he agreed to treatment in a RTC after he relapsed. The patient was discharged from the RTC after trying to sell substances and shoplifting from a local store while out on a pass. 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 endorsed smoking heroin on a daily basis for the past three years. He has been treated in a chemical dependency rehabilitation program on several occasions over the past five years. The providers noted that the patient has been inconsistent with his providers treatment recommendations and he has demonstrated minimal motivation. The patient relapsed and was briefly in an RTC for two weeks until he was discharged for rule violations. The patient and his mother report that the patient has been in a relapse and using heroin continuously or going through periods of withdrawal since leaving RTC. Thus, despite recent, active participation in treatment at less intensive level of care, the patient continues to use drugs, with imminent serious consequences, and is at high risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient is homeless but temporarily allowed to stay with his mother. The patients mother is in recovery from addiction and there is a high level of conflict in the home. The patient has legal problems related to drug charges and shoplifting. The patient is unemployed, socially isolated, and lacks a sober support system. The patient was unable to maintain sobriety while treated with suboxone at the intensive outpatient program level of care for any significant period of time. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for Level 3.5 RTC services. Moreover, the requested 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. Per ASAM, the duration of treatment is determined by the patients progress in meeting treatment plan goals rather than a predetermined number of days. Therefore, the requested RTC services (ASAM Level 3.5) are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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.