Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for RTC level of care. Findings:  The physician reviewer found that this patient meets Level 3.1 criteria for RTC level of care. 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 treated for withdrawal with a diazepam taper. The patients withdrawal needs were safely managed in level 3.1 setting. For dimension 2, the patient has asthma. The patients biomedical problems are stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient has anxiety and depression. He has a history of self-harm by burning himself and endorses passive suicidal ideation. He reported binge drinking, driving while under the influence, getting into physical altercations when drinking, and engaging in risky behaviors, including jumping out of a moving vehicle while intoxicated, breaking both his arms. While at the RTC, the records noted significant anxiety with panic attacks. The patient participated in group therapy. The patients mental status was stable enough to permit participation, and his anxiety and depression may be related to his substance use problem, with imminent likelihood of relapse with dangerous consequences outside of a structured environment. For dimension 4, the patient admitted himself to the RTC due to feeling overwhelmed and depressed with his ongoing substance use. He acknowledged that he had lost control of his alcohol and drug use with negative consequences including relationship discord with his family and roommate, and dangerous behaviors while intoxicated. 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 has been using alcohol and cannabis since age nine. He reported drinking heavily daily for two years, along with daily Xanax and cannabis use. At the RTC, he reported cravings and urges for alcohol, and felt that he did not have coping skills to maintain sobriety in the community. Despite recent, active, participation in treatment at a less intensive level of care the patient continued to use drugs with imminent serious consequences and was at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient lives with roommates that regularly drink and use cannabis. The patients social network includes regular users of drugs such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets 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, the RTC level of care 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.