Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) for a minimum of 90 days. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 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 admitted to RTC after completing a 10-day detoxification at a different facility. She continued to have withdrawal symptoms including agitation, anxiety, hallucinations, and gastrointestinal upset. The patients withdrawal needs could have been safely managed in Level 3.1 setting. For dimension 2, the patient does not have any medical problems. The patients biomedical problems were stable and did not require medical or nurse monitoring. For dimension 3, the patient has significant difficulties with acute PTSD, anxiety, and an eating disorder. She participated in groups and was described by the providers as constantly anxious. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition was stable, and he was assessed as having minimal problems in this area as evidenced by anxiety that may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment. In addition, the patient was assessed as not posing a risk of harm to self or others. For dimension 4, the patient admitted herself for treatment after a four-day binge on methamphetamine and experiencing a psychotic episode that resulted in her arrest. She has tried on several occasions to stop using alcohol and Xanax and has been unable to do so despite negative consequences. She expressed a desire to remain clean and abstinent and was able to identify negative consequences of her addiction. The patient acknowledged the existence of a psychiatric condition and substance use problem. She recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient endorsed drinking alcohol in combination with Xanax for several years. She is also on 16 mg of suboxone daily. She started using methamphetamine and experienced psychotic episodes with dangerous behaviors. She also used methamphetamine on the day between her 10-day detoxification and admission to the RTC. The patient demonstrated limited coping skills to address relapse triggers and urges. She was in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient was living with her boyfriend who also uses substances, and she was unable to return to that apartment. She was unemployed due to her substance usage and she had difficulty accepting responsibility for her actions. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment made recovery unlikely and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services, for a total treatment plan of a minimum of 90 days were and are medically necessary for this patient. Final Result: The reviewer determined that the services at issue were and 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.