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) services, specifically ASAM level 3.5. Per American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC services from 1/24/22 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 management for opioid withdrawal, sedative-hypnotic use disorder, and alcohol use disorder. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient does not have acute medical problems. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient does not appear to be an imminent danger to himself or to others. The patients mental status was stable enough to permit participation in the therapeutic interventions provided at this level of care and to benefit from treatment.For dimension 4, the patient is noted as having no insight into his drug use, normalizing his substance use as part of his generation. The patient blamed his girlfriend rather than his addiction for a recent overdose. He was noted as minimally engaging in groups. The patient has limited insight and little awareness of the need for continuing care or the existence of his substance use or mental health problem and need for treatment, and thus has limited readiness to change. For dimension 5, the patient reported that music and his brothers death are his relapse triggers but is not motivated to avoid these triggers and lacks insight into the benefits of care. The records noted that the patient was at high risk of relapse outside of treatment. The patient had a recent overdose on fentanyl. The patients continued substance use poses a danger of harm to self, he has limited ability to interrupt the relapse process or continued use, or to use peer supports when at risk for relapse to his addiction or mental disorder, and is unable to control his use of alcohol, other drugs, and/or antisocial behaviors, with attendant probability of harm to self or others.For dimension 6, the patient reported that he slept on the couch at his mothers boyfriends house. His living environment is not supportive, and he is surrounded by people who use alcohol and other substances. The patient is noted to have no positive therapeutic relationships. The patients social network includes regular users of substances, such that recovery goals are assessed as unachievable at a less intensive level of care.Given these findings, the patient meets the six ASAM criteria for RTC services. Secondary to the fact this patient has very little recognition of the negative consequences of his actions, care at any level below Level 3.5, such as Level 3.1, would not be appropriate. The records noted that a primary trigger for relapse for this patient is being outside the confines of a 24-hour monitoring RTC, and that during a previous RTC stay, the patient relapsed when leaving the program against medical advice. For these reasons, he does not yet appear to be able to cope outside a Level 3.5 treatment setting. 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, the RTC services, specifically ASAM level 3.5, 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 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.