Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the RTC services for substance abuse disorder, specifically ASAM level 3.5. Medical criteria this patient met level 3.5 criteria for RTC services provided.  For dimension 1, the patient was managed for withdrawal for post-acute-withdrawal symptoms (PAWS) consistent with opioid withdrawal. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with major depressive disorder along with opioid and amphetamine use disorders. They reported using heroin and methamphetamine daily for years. They had a history of 14 overdoses, requiring Narcan, with the most recent overdose shortly before admission to the RTC. They had a history of three prior treatment attempts, relapsing quickly after each discharge. The patients mental status was stable enough to permit participation, they demonstrated a repeated inability to control their impulses to use substances, and was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient was admitted voluntarily for treatment after relapsing shortly after being discharged prematurely from another RTC. They had multiple arrests due to their drug usage, and was facing a federal charge. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery. For dimension 5, the patient had a history of three prior treatment attempts, with the longest period of sobriety being less than 15 days. They had numerous stressors and attributed relapse on external stressors. They left treatment against staff advice. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care, and was therefore not committed to treatment. Their continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support.For dimension 6, the patient had not been able to cope without using substances outside of a residential setting except for a two week period. They had severe psychosocial stressors including unemployment without an income, homelessness, and legal issues. They had a very limited sober support system consisting of one friend. 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. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the RTC services for substance abuse disorder, specifically ASAM level 3.5, were medically necessary for 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.