Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for ASAM 3.5 residential treatment center (RTC) services provided by Cliffside Malibu II Inc. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services from 11/15/21 going forward. 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 underwent management for withdrawal from benzodiazepines earlier in her stay. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient has hypertension. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient has severe anxiety, depression, and passive suicidal ideation. The patient reported keeping a stash of Xanax. She reported wanting to go to sleep and not wake up, and the notes indicated a moderate risk for suicide. The patient had a history of cutting and of seven psychiatric hospitalizations. The patients mental status was stable enough to permit participation, her psychiatric condition is stabilizing. However, despite her best efforts, the patient is unable to control her use of drugs without attendant probability of imminent danger.  The resulting level of dysfunction is so severe that it precludes the patient's participation in a less structured and intensive level of care. For dimension 4, the patient was admitted voluntarily for treatment due to increased Xanax usage of taking four pills at once. She reported using Xanax to manage increased stress from conflict with family and blamed them and their verbal abuse for her Xanax addiction. The patient attributed her drug, addictive, or mental problems to other persons or external events, rather than to a substance use or addictive or mental disorder. For dimension 5, this was the patients second attempt at treatment. The records noted that the patient was at an RTC six years ago and maintained sobriety for two months. The patient reported using Xanax to manage depression and anxiety and blamed her family for her increased usage. She was unemployed due to her substance usage, did not have a place to live, and had a troubled relationship with most of her family, being estranged from all but one of her children. She reported suicidal ideation while at the RTC, reported keeping a stash of Xanax, and was noted as being at moderate risk of suicide. The patient requires 24-hour monitoring and structured support, does not recognize relapse triggers and has little awareness of the need for continuing care and is therefore not committed to treatment.  Her continued substance poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support.For dimension 6, the patient was homeless and unemployed due to her substance use. Her only supports were one son, a cousin, and her best friend. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. She needs 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 and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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, ASAM 3.5 RTC services provided by Cliffside Malibu II Inc. were and are medically necessary for treatment of 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 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.