Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 35-year-old male who was initially admitted on 1/07/22 for treatment of 
amphetamine use disorder. The patient has requested reimbursement for residential substance 
abuse treatment at Harmony Place provided from 1/21/22 through 1/30/22. The physician 
reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, this patient 
met Level 3.5 criteria for residential treatment center services provided from 1/21/22 through 
1/30/22. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. 
Dimension 1 involves acute intoxication or withdrawal potential. The patient did not require 
withdrawal management during this portion of his treatment. The patient met the sub-criteria of 
withdrawal needs can be met in Level 3.5 setting. Dimension 2 involves biomedical conditions. 
The  patient  does  not  have  active  medical  problems.  The  patient  met  the  sub-criteria  of 
biomedical  problems,  if  any,  are  stable.  Dimension  3  involves  emotional,  behavioral,  or 
cognitive conditions. The patient has been diagnosed with depressive disorder and stimulant-
induced psychosis. Records indicate that he was severely depressed with impaired activities of 
daily living and difficulty participating in groups. He was prone to sleeping and isolating himself. 
He was also delusional about having past lives and needing to be high on methamphetamine to 
access these memories. He continued to feel that he needed to use methamphetamine to have 
these experiences. He assaulted his mother in December 2021 while high on methamphetamine 
and was arrested for elder abuse. The patient meets sub-criteria of mental status permits 
participation, and the patients psychiatric condition is stabilizing. However, despite his best 
efforts, the patient is unable to control his use...with attendant probability of imminent danger. 
The resulting level of dysfunction is so severe that it precludes the patients participation in a less 
structured and intensive level of care. Dimension 4 involves readiness to change. The patient 
was admitted voluntarily for treatment only after his family staged an intervention after he 
assaulted his mother. He then went to a motel for three weeks to use methamphetamine daily 
prior  to  agreeing  to  enter  treatment.  He  has  not  worked  in  three  years  due  to  his 
methamphetamine  usage.  This  patient  was  noted  to  have  poor  insight  into  his 
methamphetamine usage and to have limited readiness to change. He had minimal awareness of 
negative consequences of using. The patient met the sub-criteria of because of the intensity and 
chronicity of the addictive disorder, he has limited insight and little awareness of the need for 
continuing care or the existence of his substance use and need for treatment, and thus has 
limited readiness to change. Dimension 5 involves relapse, continued use, and continued 
problem potential. This patient had prior attempts at treatment with residential stays in 2020 
and 2021. His longest sobriety was seven months. He had not been able to identify relapse 
triggers. He was noted to have minimal insight into the role that his psychiatric diagnosis of 
depression played in his using methamphetamine. His methamphetamine usage has been severe 
in that he has been unable to work for three years and is completely reliant on his parents. He 
assaulted his mother in December while high and then spent days in jail. He then continued to 
use for three more weeks after his release from jail. The patient met the sub-criteria of  the 
patient does not recognize relapse triggers and lacks insight into the benefits of continuing care, 
and is therefore not committed to treatment. His continued substance use poses an imminent 
danger of harm to self or others in the absence of 24-hour monitoring and structured support. 
Dimension 6 involves recovery environment. He had been staying in motels after his family kicked  him out of the house due to assaulting his mother. He is unemployed and has no current income. 
He is socially isolated and has no friends or sources of social support. He was noted to be avoidant 
of others and had limited participation during treatment. The patient met the sub-criteria of the 
patients social network is characterized by significant social isolation or withdrawal, such that 
recovery goals are assessed as unachievable at a less intensive level of care. All told, residential 
substance abuse treatment at Harmony Place provided from 1/21/22 through 1/30/22 was 
medically necessary for the treatment of this patient.