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) (ASAM Level 3.5) 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. The 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 for opioid withdrawal and transitioned to suboxone dosage. The patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient has neuropathy and asthma. 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 been diagnosed with anxiety disorder and bipolar disorder. She has been unable to control impulses to use IV methamphetamine in the community and in the facility. She has history of overdose and a car accident while intoxicated. The patient has continued to have cravings and anger dyscontrol. The records document that the patients mental status has been assessed as sufficiently to stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. In addition, the patient demonstrates repeated inability to control her impulses to use alcohol and other drugs or to engage in antisocial behavior and is in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was voluntarily admitted to RTC for treatment after being unable to stop using IV methamphetamine, valium, methadone, and alcohol on her own. The patient endorsed using heroin since age 18 up until medication assisted treatment with methadone two years ago. The patient has struggled with participation in the treatment and was noted to be passive in her treatment. The patients perspective impairs her ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable her to develop insight into the role she plays in her substance use and empower her to make behavioral changes which can only be delivered in a 24-hour milieu. For dimension 5, the patient was started on suboxone, tapered off methadone, and she is planned to start treatment with Sublocade. The records document that the patient is experiencing addiction symptoms such as drug craving. This situation poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors. For dimension 6, the patient has not been able to cope without using substances over the past several months despite treatment with methadone. She has been unable to work and unable to see her children due to her substance use disorder. She has been in a relapse for months using in home environment. The patient has been unable to cope, for even limited periods of time, outside of 24-hour care. She needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for Level 3.5 RTC services from 10/14/21 forward. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the RTC (ASAM 3.5) level of care 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.