Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services (ASAM Level 3.5). Per the 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 underwent withdrawal management for benzodiazepine withdrawal earlier in his treatment stay. The patient demonstrated withdrawal symptoms including anxiety, diaphoresis, and tactile, auditory, and visual disturbances. The patients withdrawal needs could have been safely managed in a level 3.5 setting. For dimension 2, the patient has medical problems of asthma and cannabis hyperemesis syndrome. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient reported that he has used Xanax to manage his anxiety since age 16 with dosage increasing to 8-10 mg daily. He has a history of blackouts and he has been unable to control his impulses to take Xanax prior to RTC due to physiological withdrawal. He has continued to complain of anxiety and insomnia exacerbated by withdrawal symptoms. The patients mental status was assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition was stabilizing. However, despite his best efforts, the patient was unable to control his use of Xanax with attendant probability of imminent danger. The resulting level of dysfunction was of such severity that it precluded participation in a less structured and intensive level of care. For dimension 4, the patient was admitted voluntarily for treatment. The patient endorsed use of Xanax daily for five years, cannabis daily for seven years, and cocaine daily for the past 18 months. This patient has been using high amounts of Xanax and cannabis daily since adolescence, age 16, and has not developed coping skills to cope with stressors. Because of the intensity and chronicity of the addictive disorder, the patient had limited insight and little awareness of the need for continuing care or the existence of his substance use and need for treatment, and thus had limited readiness to change. For dimension 5, the patient has not had prior attempts at treatment. He has been taking 8-10 mg of Xanax daily for five years, using cannabis daily since age 14, and more recently started snorting 1 gram of cocaine daily for the past 18 months. He has history of blackouts. He has depression and anxiety and has been using Xanax, cannabis, and cocaine to manage his anxiety and mood. He admits to having had suicidal ideation with thoughts of shooting himself. He experienced cravings, anxiety, depression, and insomnia and underwent psychopharmacologic management to reduce these symptoms. The patient was experiencing psychiatric or addiction symptoms such as drug craving. This situation posed 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 psychiatric or addictive symptoms, such as cravings, that would have enabled the patient to delay immediate gratification and reinforce positive recovery behaviors. For dimension 6, the patient has been living with his father who is an alcoholic and drinks in the home. His father is not supportive of the patient or his recovery efforts. The patients social network included living with an individual who is a regular user, addicted user, or dealer of alcohol or other drugs, or the patients living environment was so highly invested in alcohol and/or other drug use that his recovery goals were assessed as unachievable. Given these findings, the patient met the six ASAM dimensions to support RTC services. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the RTC services (ASAM level 3.5) were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.