Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for any or all of RTC level of care services. Findings:  The physician reviewer found that (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 managed with Librium for withdrawal from opioids and benzodiazepines. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient has chronic obstructive pulmonary disease (COPD) and is managed on two liters of oxygen, type 2 diabetes, and hypertension. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient has been diagnosed with generalized anxiety disorder and recurrent major depressive disorder. The patient had been prescribed lorazepam and hydrocodone daily for 15 years. She reported overtaking prescribed lorazepam and Norco such that she was running out of medications and presented at the emergency room in efforts to obtain more medications. The patients mental status was stable enough to permit participation, she demonstrated a repeated inability to control her impulses to use substances, and she was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient was admitted voluntarily for treatment at the urging of her siblings. The patient continued to take higher dosages of lorazepam and Norco daily and was presenting to the emergency room with severe anxiety in attempts to obtain lorazepam. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care. For dimension 5, the patient had been prescribed three mg of lorazepam and up to three 10/325 mg of Norco daily for 15 years. She was abusing substances by taking higher than prescribed amounts of Norco and lorazepam, a potentially lethal combination.  During her RTC stay, she was managed with Librium for withdrawal and her symptoms included ongoing tremors, bone and joint aches, and anxiety. The patient had difficulty tolerating somatic symptoms. The patient was experiencing psychiatric or addiction symptoms such as drug craving, insufficient ability to postpone immediate gratification, and other drug-seeking behaviors, posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support was indicated to decrease addictive symptoms to enable the patient to delay immediate gratification and reinforce positive recovery behaviors.For dimension 6, the patient was single and lived with her sister. She was employed as the Chief Financial Officer of her familys logging business. She was unable to cope with the prescribed dosages of benzodiazepines and was resorting to presenting to the emergency room to attain more medications. The patient was unable to cope, for even limited periods of time, outside of 24-hour care and needed staff monitoring to learn coping strategies prior to being transferred safely to a less intensive setting.Given these findings, the patient met the six ASAM criteria for RTC level of care. 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, RTC level of care provided was and is 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.