Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) level of care services. 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 did not have any post-acute withdrawal symptoms. She was previously treated in a psychiatric hospital for acute psychosis and delusions, stepped down to partial hospitalization program (PHP), and then transitioned to RTC. For dimension 2, the patient did not have any reported biomedical problems. For dimension 3, the patient was recently diagnosed with schizoaffective disorder and had ongoing psychotic symptoms of auditory and visual hallucinations as well as grandiose delusions. Prior to admission, the patient threatened to kill her mother and she was served with a restraining order. By the time of discharge, the patients mother was willing to allow the patient to return home. 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 patient demonstrated significant functional deficits, which were likely to respond to staff interventions. These deficits were sufficiently severe that the patient was not likely to maintain mental stability or abstinence if treatment is provided in a non-residential setting. In this case, the patients deficits included residual psychiatric symptoms. For dimension 4, the patient lost custody of her children and has been unemployed for two years due to her substance use disorder, and her mother served her with a restraining order due to aggressive behavior. The provider noted that the patient demonstrated poor insight into these consequences and blamed others for her problems. Despite experiencing serious consequences, the patient had marked difficulty in understanding the relationship between her substance use, addiction, mental health, and impaired coping skills. The patient often blamed others for her addiction problems. For dimension 5, the patient used methamphetamines and opiates until April 2020. She endorsed ongoing cravings to use methamphetamines. She failed to understand her continued need for treatment in the RTC setting and she blamed her mother for their conflict and the restraining order. Her psychosis slowly improved and she was less fixated on her delusions, but she continued to have periods of isolation with lack of participation, and she continued to blame others for her problems. The patient was in imminent danger of relapse or continued use, with dangerous emotional and behavioral consequences as a result of a crisis situation. For dimension 6, the patient lived with her mother due to her recent divorce, she did not have social supports, and she has not worked in two years. The patients mother permitted her to return home and attend IOP level of care. The patients social network is characterized by significant social isolation or withdrawal, such that recovery goals were assessed as consistently unachievable in a less intensive level of care. Given these findings, the patient met the six ASAM dimensions for RTC level of care. Therefore, the RTC level of care services 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.