Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center level of care.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient did not meet Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, detoxification/withdrawal potential, the patient was noted to have some difficulty coping with withdrawal discomfort. On the first date of services at issue, the patients Clinical Opiate Withdrawal Scale (COWS) score ranged from 8 to 13, and he was treated with Suboxone. The patient had been treated with seven days of buprenorphine and a Librium taper, despite denying alcohol use in the past three years and confirmatory testing for alcohol on admission was negative. The patients risk rating for this dimension is 2, or moderate. For dimension 2, biomedical conditions and complications, the patient had a history of testicular cancer and no other active medical problems. Therefore, the patients risk rating for this dimension is 0, or minimal or no observable risk. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patient had a history of unspecified depressive disorder and unspecified anxiety disorder. He had been treated by his primary care physician with no history of psychosis, suicidal ideation or homicidal ideation. The patient also had a history of trauma due to the possible murder of his mother by his stepfather, and his emotional symptoms distracted from recovery efforts. The patients psychiatric symptoms were not well stabilized, but he was compliant with his medications. The patients risk rating for this dimension is 2, or moderate. For dimension 4, readiness to change, the patient was willingly engaged in treatment as a proactive participant, and he was aware of and admitted to having an addiction problem. The patient was committed to addiction treatment and changing substance use. The patients risk rating for this dimension is 1, or mild. For dimension 5, relapse, continued use, or continued problem potential, the patient experienced cravings and was prescribed Suboxone. He was noted to be impulsive, and he had repeated treatment episodes. The patients risk rating for this dimension was 4, or substantial. For dimension 6, recovery/living environment, the patient lived with his girlfriend, who was in recovery and was supportive. There were no drugs or alcohol in the home, and there were no logistical barriers to treatment or recovery. Therefore, the patients risk rating for this dimension is 0, or minimal or no observable risk. Using the ASAM level 3.5 criteria worksheet, the patient does not meet criteria for medical necessity on dimension 2, biomedical, or on dimension 6, recovery environment and therefore did not qualify for ASAM Level 3.5 treatment, which is similar to what the patient received at the facility. Accordingly, the Residential Treatment Center level of care was not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary to treat the patients condition. Therefore, the Health Plans denial should be upheld.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.