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. Per 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, there have been no withdrawal issues of concern. The patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient does not have active medical problems. 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 patients diagnoses include methamphetamine use disorder and cannabis use disorder. The patient endorsed smoking 14 ounce of methamphetamine daily for 20 years. He has been living with his drug dealer and his mother and sister are also addicted to methamphetamine. He also reported symptoms consistent with gambling disorder. He has ongoing difficulty with delaying gratification and impulse control due to his chronic addictive disorder. He has demonstrated severe dysfunction including problems with authority, and he has been a potential for harm to others. The provider noted that the patient has been participating in groups. The patients mental status has been 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 demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction is so severe that it precludes the patients participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted voluntarily due to severe consequences of his 20-year addiction to methamphetamine including a divorce, inability to see his children, and homelessness. This is the patients first attempt at treatment. The provider noted that the patient is in the precontemplative stage of change. He does not take full responsibility for his legal history and charges. The patient demonstrates antisocial behavior patterns that have led to significant criminal justice problems, lack of concern for others, and extreme lack of regard for authority, which prevents movement toward positive change and precludes participation in a less structured and intensive level of care. The patient demonstrates passive or active opposition to addressing the severity of his mental or addiction problems or does not recognize the need for treatment. Such continued substance use or inability to follow through with mental health treatment poses a danger of harm to others. However, assessment indicates that treatment interventions available at Level 3.5 may increase the patients degree of readiness to change. For dimension 5, the patient has been using 14 ounce of methamphetamine on a daily basis for the past 20 years. He has no history of sobriety and has never been in treatment. He is seeking treatment due to consequences of his years of addiction that now include homelessness, legal charges, and inability to see his children. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. His continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient is going through a divorce and he was staying with his girlfriend who uses substances. His mother and sister are also addicted to methamphetamine. His social network consists of drug dealers and other users. The patients  social network includes regular users of alcohol and other drugs such that recovery goals are assessed as unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. 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 services (ASAM Level 3.5) 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.