Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for substance abuse residential treatment center (RTC) services. Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria, this patient met the 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 patient denied use of alcohol, benzodiazepines, or opioids for three weeks prior to admission and the patient did not require withdrawal management. The patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient did not have any reported medical problems. The patients biomedical problems, if any, are stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient was admitted voluntarily for treatment after being suspended from college due to making homicidal threats online while intoxicated. The patient was initially at a psychiatric facility near his college and was diagnosed with major depressive disorder. The patient reported self-loathing and passive suicidal ideation. He has history of threatening and fighting with others when intoxicated. He was noted to have traits suggestive of a cluster B personality disorder. Overall, the records support that the patients mental status was 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 demonstrated repeated inability to control his 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 was of such severity that it precluded participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was suspended from college due to making homicidal threats on social media. The patient reported self-loathing and endorsed use of substances to distract himself from his situation. Despite experiencing serious consequences or effects of the addictive disorder, the patient had marked difficulty in understanding the relationship between his substance use, addiction, mental health, or life problems and his impaired coping skills and level of functioning. For dimension 5, this is the patients first attempt at treatment per the records. The patient is facing legal consequences for making homicidal threats online while intoxicated. The patient has demonstrated steadily escalating substance usage since attending college including daily cocaine and heroin usage. The patients psychiatric condition was stabilizing. However, despite his best efforts, the patient was unable to control his use of drugs, with attendant probability of harm to self or others. The patient had limited ability to interrupt the relapse process or continued use. His continued  substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient was suspended from college a few weeks before admission. Due to the pandemic restrictions, there are no available PHP programs. The patients friend group all use substances. The patients social network included regular users of alcohol and other drugs, such that recovery goals were assessed as unachievable at a less intensive level of care. Based on these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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.