Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that  the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 patients withdrawal needs can be met in Level 3.5 setting. The patient still has mild to moderate withdrawal symptoms of agitation, anxiety, diaphoresis, and tachycardia. He was managed for sedative-hypnotic withdrawal with a Librium taper. For dimension 2, the patient has history of complex partial seizures, which reportedly required hippocampal surgery. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has diagnoses of schizoaffective disorder-depressive type, anxiety, and agoraphobia. He was noted to have delusions about recent events and to have problems with reality testing. The patient also reported hearing voices. His mental status is 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 has significant functional deficits which are likely to respond to staff interventions. These symptoms are sufficiently severe that the patient is not likely to maintain abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature...and include residual psychiatric symptoms. For dimension 4, the patient agreed to an admission after relapsing and being asked to leave his sober living environment after 30 days. He then made a suicide attempt via overdose on the way to the RTC and needed a brief medical admission. The patient requires 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 in a relapse after a 30-day period of abstinence in a sober living environment. He previously left treatment against medical advice in April 2020 after five days due to agitation and began using substances immediately on discharge. He impulsively took an overdose of medications when he was last drinking alcohol. The patient is in imminent danger of relapse or continued use, with dangerous emotional, behavioral, or cognitive consequences, as a result of crisis situation. For dimension 6, the patient is homeless. He was asked to leave his sober living environment after he relapsed. He has been unemployed since 2015 and has legal difficulties due to ongoing drug usage. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with dimension 6 problems before being transferred to a less intensive setting. Given these findings, the patient meets the ASAM criteria for RTC services. Thus, the RTC services were and are 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 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.