Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for all or any of the requested residential treatment center (RTC) services, specifically ASAM Guideline Level 3.1, provided at The Lakes Treatment Center from August of 2021, and forward.At issue is whether all or any of the requested residential treatment center (RTC) services, specifically ASAM Guideline Level 3.1, provided at The Lakes Treatment Center from August of 2021, and forward were and are medically necessary for treatment of the patients mental health or substance use disorder as defined in Health and Safety Code section 1374.72(a)(3)(A) set forth below. Medically necessary treatment of a mental health or substance use disorder means a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) In accordance with the generally accepted standards of mental health and substance use disorder care. (ii) Clinically appropriate in terms of type, frequency, extent, site, and duration. (iii) 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.Per the American Society of Addiction Medicine (ASAM) criteria, this patient met and meets Level 3.1 criteria for RTC services for the dates of 8/11/21 and 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 withdrawal management for alcohol withdrawal and sedative-hypnotic withdrawal with Librium earlier in his treatment stay. Based on clinical findings, the patients withdrawal needs could have been safely managed in a Level 3.1 setting.For dimension 2, the patient does not have any medical problems. The patients biomedical problems were and are stable. He does not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications.For dimension 3, the patient was noted to be anxious and had difficulty managing anxiety and participating in groups. The patient has been drinking and using benzodiazepines daily to manage this. He was noted to lack knowledge of other coping skills. The patient has been undergoing psychopharmacologic management to treat his generalized anxiety disorder. He has participated in groups. Based on these findings, the patient met and meets the requirements for this dimension.For dimension 4, the patient was admitted voluntarily for treatment after he accidentally overdosed on Klonopin while drinking and was hospitalized in July. The patient was able to acknowledge negative consequences of his substance usage. Based on these findings, the patient met and meets the requirements for this dimension. For dimension 5, the patient has been drinking a fifth of vodka and combining it with benzodiazepines on a daily basis for the past three years. The patient had an accidental overdose necessitating hospitalization in July and a driving under the influence (DUI) charge in June. He relapsed immediately when he returned home after the past two attempts at treatment. Based on these findings, the patient met and meets the requirements for this dimension.For dimension 6, the patient was living with his parents and girlfriend but was kicked out after they discovered his girlfriend was sneaking him alcohol. The patient is now homeless and socially isolated. The patient does not appear to have a sober social support network. He is reported as having little knowledge of coping skills or relapse triggers. Based on these findings, the patient met and meets the requirements for this dimension.The ASAM criteria requires adult patients to meet all six dimensions to support residential treatment center services. This patient did meet all the dimensions for Level 3.1 residential treatment center criteria. Moreover, the services were and are in accordance with the generally accepted standards of mental health and substance use disorder care. 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. Given these findings, the RTC services, specifically ASAM Guideline Level 3.1, provided at The Lakes Treatment Center from August of 2021, and forward 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.