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 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 management for opioid withdrawal and medication assisted treatment with suboxone. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had chronic pain, which the records noted was a trigger for substance use, and a diagnosis of fibromyalgia. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with PTSD and had a history of trauma. The patient reported using heroin and methamphetamine daily for the past two months, with regular usage over the past two years. She had difficulty regulating her emotions in group sessions and when speaking with family members, often leading to episodes of screaming. The patients mental status was stable enough to permit participation. However, she demonstrated a repeated inability to control her impulses to use substances and/or antisocial behaviors, with attendant probability of imminent danger and a resulting level of dysfunction so severe that it precluded the patients participation in a less structured and intensive level of care.For dimension 4, the patient was admitted voluntarily for treatment. She reported that she had been using heroin and methamphetamine intravenously for two months, with regular usage over the past two years, and that she was tired of using substances. The records noted a history of relapses following detoxification and residential treatment programs. The records noted that the patient  struggled with participation in treatment and had limited insight into her addiction. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions had not succeeded at less intensive levels of care. For dimension 5, the patient was put on suboxone maintenance but continued to endorse ongoing cravings, irritability, and insomnia. She was prescribed psychotropic medications for symptoms that could trigger relapse. The patient was experiencing addiction symptoms such as drug craving, posing an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support was indicated to decrease addictive symptoms, such as cravings, to enable the patient to delay immediate gratification and reinforce positive recovery behaviors.For dimension 6, the patient had been unemployed for two years and homeless for the past year.  The patient reported wanting to remain in a relationship with her partner, who had introduced her to intravenous drugs, despite the high risk for relapse. She had been unable to cope with trauma symptoms or with current stressors without using substances outside of detoxification or residential treatment settings. The patient was unable to cope, for even limited periods of time, outside of 24-hour care and required staff monitoring to learn to cope with problems before being transferred safely to a less intensive setting.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 a 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, 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 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.