Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any of the residential dual diagnosis substance misuse treatment services at The Lakes Treatment Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for residential treatment center (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 completed a suboxone taper and was symptomatic with opioid withdrawal. The patients withdrawal needs are safely managed in level 3.1 setting. For dimension 2, the patients does not have any medical conditions. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring. For dimension 3, the patient has a diagnosis of major depression. He has legal problems secondary to substance abuse and the records note that he is mandated to participate in a 90-day program. The patient participated in group therapy. The patients mental status is stable enough to permit participation and his depression may be related to substance use problems with imminent likelihood of relapse with dangerous consequences outside of a structured environment.For dimension 4, the patient is mandated to participate in a 90-day program. The patient reported that he risked losing his girlfriend of five years if he continued his substance abuse. The patient acknowledged the existence of a substance use problem and recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. The patient is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5, the patient has been using opiates and methamphetamines since age 26. He relapsed immediately following a prior discharge from RTC. He is transitioning from suboxone to vivitrol and coping with symptoms of opioid withdrawal. The patient demonstrates limited coping skills to address relapse triggers and urges and is in imminent danger of relapse with dangerous consequences in the absence of close 24-hour monitoring and structured treatment.For dimension 6, the patient is unemployed. He has legal issues due to his substance usage. The patient's living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning at a less intensive level of care.Given these findings, the patient meets the six ASAM criteria for RTC services. 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, all residential dual diagnosis substance misuse treatment services provided at The Lakes Treatment Center 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 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.