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, the patients last use of opiates was a few days prior to admission and last use of methamphetamine was on the day of admission. She had withdrawal symptoms of cravings, irritability, anxiety, and insomnia. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient has asthma. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring. For dimension 3, the patient has history of anxiety and attention deficit disorder (ADD). Three days before admission to RTC, she underwent detoxification from opiates, left the facility, and used IV methamphetamine the same day. She is also on probation for legal issues related to her substance use disorder. She admits that she has been using heroin, fentanyl and methamphetamine and driving while under the influence. The patients mental status permits participation. She demonstrates antisocial behavior patterns that have led to significant criminal justice problems, lack of concern for others, and precludes participation in a less structured and intensive level of care. For dimension 4, the patient has poor insight and awareness into her continued need for care. She was noted to be ambivalent about her need for ongoing treatment. She must complete this treatment program or face return to jail. Due to the intensity and chronicity of the patients addictive disorder, she has limited insight and little awareness of the need for continuing care and thus has limited readiness to change. For dimension 5, the patient was reportedly sober for 18 months prior to relapsing on heroin, fentanyl, and methamphetamine in May 2020. She started using heroin 20 times per day until she presented for detoxification. She overdosed on fentanyl and needed Narcan. She relapsed on methamphetamine the first day after release after detoxification from opiates. She is having cravings to use and has previously abused suboxone. The patients psychiatric condition is stabilizing. However, despite her best efforts is unable to control her use of drugs with attendant probability of harm to self or others. The patient has limited ability to interrupt the relapse process or continued use and poses an imminent danger to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient lives with a roommate that uses substances, and her boyfriend is currently in rehabilitation for heroin use. She has been unemployed and has no structure in her life. The patients social network includes regular users of drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC 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.