Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) all or any of the RTC services, and (2) readmission to the RTC.At issue is whether all or any of the residential treatment center (RTC) services were medically necessary to treat the patients mental health or substance use disorder 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 American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. 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 was noted to have withdrawal symptoms of anxiety and impaired memory. The patients withdrawal needs were safely managed in level 3.5 setting. For dimension 2, the patient had a fractured anterior cruciate ligament (ACL) in high school and vertigo. The patients biomedical problems were not severe enough to warrant inpatient treatment and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had a diagnosis of major depressive disorder. He reported several challenges over the past year including the suicide of his best friend, the murder of his nephew, the separation and pending divorce from his spouse, job loss and his grandmothers death. He was living alone and unable to cope with his grief and loss without substance use. The patients mental status was stable enough to permit participation. He had significant functional deficits that were sufficiently severe that he was not likely to maintain mental stability and abstinence in a nonresidential setting.For dimension 4, upon admission, the records noted that the patient was externally motivated due to receiving his third charge of driving under the influence (DUI) and the requirement of wearing an ankle bracelet.  He attributed his substance use to the numerous losses he experienced over the past year. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions are not feasible or likely to succeed at less intensive levels of care. For dimension 5, this is the patients first attempt at formal treatment. He reported heavily drinking since age 14 without a documented period of sobriety. He used drinking as a means of coping with loss. He had a diagnosis of depression and was passively suicidal upon admission to the RTC. He had a history of three DUIs.  At the RTC, he reported significant urges to drink and was considering starting naltrexone. Despite his best efforts, the patient continued to use drugs with imminent serious consequences and was at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment.For dimension 6, the patient was recently separated from his spouse and living alone. He reported difficulty coping with the separation. He had a limited sober support network. The patients living environment was such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care, and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, RTC services were medically necessary for the treatment of this patient.At issue is whether readmission to the RTC is medically necessary to treat the patients mental health or substance use disorder 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.The submitted documentation does not support the medical necessity of the requested services. Records reported that the patient was assessed as being at low risk of danger to himself or others and had a good recovery plan in place. In this patients case, RTC level of care is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are 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. Therefore, readmission to the RTC is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.