Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) level of care services (ASAM 3.1 to 3.7).  Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.1 or higher criteria for RTC services based on the records provided. The 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 patients records do not support an indication for withdrawal management services. The patients withdrawal needs can be safely managed in a Level 3.1 setting. For dimension 2, the patient has HIV and asthma. The patients biomedical problems are stable and do not require medical or nurse monitoring and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has a history of depression, anxiety, and gender dysphoria. He is noted to have difficulty with impulsivity. He is not psychotic, and he denies suicidal and homicidal ideation. The patients mental status is stable to permit participation. However, the records do not document that the patients thought disorder, anxiety, guilt, and/or depression may be related to substance use problems or to a stable co-occurring emotional, behavioral, or cognitive condition, with imminent likelihood of relapse with dangerous consequences outside of a structured treatment environment, or that the patients symptoms and functional limitations, when considered in the context of his home environment, are sufficiently severe that he is assessed as not likely to maintain abstinence if treatment provided in a nonresidential setting. There is a lack of documentation that the patient demonstrates an inability to maintain stable behavior over a 24-hour period without the structure and supervision of a 24-hour setting. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 4, the patient presented for outpatient treatment voluntarily in January 2022, but he did not participate in a March 2022 session and then presented with request for inpatient rehabilitation in April 2022 due to relapse. The patients records do support that the patient acknowledges the existence of a substance use problem and recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change. There is a lack of evidence that the patient is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1, that he requires a 24-hour structured milieu, or that his perspective impairs his ability to make behavior changes without the support of a structured environment. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 5, the patient endorsed use of IV methamphetamine for eight months with a 3.5-week period of abstinence in January 2022. The patient experienced a relapse in April 2022. However, there are no reports of dangerousness to self or others. The patients level of coping skills to address relapse triggers and urges have not been able to be assessed. Based on the documentation, the patient  does not meet the criteria of imminent danger of relapse with dangerous behavioral consequences requiring 24-hour structure to help him apply recovery and coping skills, that the patient understands his addiction or mental disorder but at risk of relapse in a less structured level of care because he is unable to consistently address either or both, or that he needs staff support to maintain engagement in his recovery program while transitioning to life in the community. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 6, the patient lives with his family and he is currently on leave from work. The records do not establish that the patient is living in an abusive environment, that he is socially isolated, or living with an individual who is addicted to alcohol or drugs. The patient was previously able to maintain sobriety in the community for a limited period of time. Based on these findings, the patient does not meet the requirements for this dimension. On review of the medical records, the patient does not meet criteria for even the lowest level of RTC services (ASAM Level 3.1). The ASAM criteria requires adult patients to meet all six dimensions to support treatment with RTC level of care services. The patient does not meet the criteria for dimensions 3, 4, 5, and 6. Moreover, the requested RTC services are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the requested RTC services (ASAM 3.1 to 3.7) are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.