Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services, specifically ASAM Level 3.5, received from Bayside Marin. 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 withdrawal management with phenobarbital for benzodiazepine withdrawal. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient has a diagnosis of Crohns disease. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had symptoms of depression and anxiety. She reported misusing Xanax to manage her anxiety since age 15, taking up to 10 mg daily over the past two months. She had been unable to control her impulses to take Xanax prior to RTC admission. The patients mental status was stable enough to permit participation, and her psychiatric condition was stabilizing. However, despite her best efforts, the patient 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 admitted herself voluntarily for treatment. She reported taking up to 10 mg of Xanax along with up to 15 mg oxycodone daily for the past two months. She reported using cannabis multiple times daily for the past three years. This patient had been using Xanax, Percocet, and cannabis regularly since age 16, and has not developed coping skills to cope with stressors. Due to 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 her substance use and need for treatment, and thus had limited readiness to change.For dimension 5, the patient reported an escalation in her usage, taking up to 10 mg of Xanax and up to 15 mg oxycodone daily, along with cannabis use. for the past two months. She reported using substances to manage her symptoms of depression, anxiety, and mood, and endorsed passive suicidal ideation when using. She underwent psychopharmacologic management to reduce symptoms of withdrawal and insomnia. The patient was experiencing psychiatric or addiction symptoms such as drug craving that 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, to enable the patient to delay immediate gratification and reinforce positive recovery behaviors.For dimension 6, the patient lived with her mother, who was alcoholic and drank in the home. Her father used cannabis regularly. Her parents were not supportive of the patient or her recovery efforts. The patient was still in high school with plans to graduate. The patients social network included regular users of alcohol and drugs such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. 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 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, specifically ASAM Level 3.5, received from Bayside Marin, were medically necessary for the 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.