Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the 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 in subacute withdrawal. The provider noted that the patient continued to experience 5/10 cravings, tactile disturbances, emotional dysregulation, suppressed appetite and insomnia. The patient engaged in risky sexual behaviors in trade for substances. Cessation of chronic GHB use leads to a discrete withdrawal syndrome resembling that of sedative-hypnotic withdrawal. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, his continued substance use posed a serious risk to his health. The patient reported a recent transition to intravenous methamphetamine and an accidental overdose in August 2019 that resulted in an admission. As noted above, tolerance to GHB develops rapidly and he remained at high risk of another accidental overdose or an adverse event given disinhibition associated with his substance use disorder given his high-risk behaviors. Moreover, he lost a significant amount of weight due to an eating disorder. For dimension 3, the patients mental status was sufficient to permit participation and he was unable to control his substance use without 24-hour support. The records report that the patient was highly impulsive and his emotional dysregulation continued during his stay. His functional deficits, such as poor appetite, poor grooming, agitation and other behaviors were likely to respond to staff intervention at the RTC level of care. For dimension 4, the patient had limited insight or awareness in his need for continuing care. The provider noted that the patient had poor motivation for change, and his perspectives glamorized some aspects of his substance abuse. The patients perspective impaired his ability to make care decisions. For dimension 5, the patient was at imminent danger of relapse or continued use with dangerous emotional, behavioral, or cognitive consequences due to a crisis. The records indicate that the patient had a labile mood, severe cravings, agitation, poor sleep, and poor appetite. The complex pharmacokinetic drug interactions between his current psychotropic medications and substances should he relapse would have presented and serious threat to his safety. For dimension 6, the patients recovery environment did not support his recovery goals. The patient was recently relapsed at a sober living facility and was homeless. He indicated that he practiced risky sexual behaviors and was couch surfing. As such, the patients social network involved regular use of substances, such that his recovery goals were unachievable at a less intensive level of care. Overall, the patients social environment was too chaotic to support his treatment goals. According to the ASAM framework, this patient met each of the six dimensions required to meet Level 3.5 criteria for RTC services. Therefore, the RTC level of care services 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 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.