Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for any or all of the residential treatment center (RTC) services at The Lakes Treatment Center (ASAM Level 3.5). Per American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 managed for opioid withdrawal. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient did not have biomedical problems and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with major depressive disorder and generalized anxiety disorder while at the RTC and started on Effexor extended release. He had attempted to stop opioid use seven times and had relapsed within three days on each occasion. He displayed impulsive behavior while at the RTC by trying to leave the facility, breaking rules, angry outbursts toward staff, and threats of suicide as a means of manipulation. The records noted an accidental overdose on fentanyl accidentally prior to admission that required emergency medical attention. The patients mental status was stable enough to permit participation, he demonstrated a repeated inability to control his impulses to use substances, and he was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient was dropped off at the RTC by his father and admitted to treatment voluntarily. The records noted that his family reported being scared of the patients aggressive behaviors. He was noted to lack any internal motivation to stop using and reported that he did not feel that he needed to continue treatment. The patient demonstrated passive or active opposition to addressing the severity of his addiction problem and does not recognize the need for treatment, with continued substance use posing a danger of harm to self or others. A possibility of increasing the patients degree of readiness to change was assessed as possible with structured therapy and a 24-hour programmatic milieu. For dimension 5, the patient reported using Percocet and fentanyl, with seven attempts at quitting, but relapsing each time. This was his first attempt at formal treatment and despite being started on suboxone to manage urges, the patient continued to display impulsive behavior, trying to leave the facility. He had a history of overdosing on fentanyl. The patient was experiencing addiction symptoms such as drug craving, insufficient ability to postpone immediate gratification, and other drug-seeking behaviors that posed an imminent danger of harm to self in the absence of close 24-hour monitoring and structured support. For dimension 6, the patient lived with his parents, who reported being frightened by the patients  aggressive behaviors. The patient was noted to be isolating. The patients social network includes regular users of drugs such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care.  Given these findings, the patient meets the six ASAM criteria for RTC services. 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 services at The Lakes Treatment Center (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 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.