Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for (1) all or any residential withdrawal management (ASAM 3.2) services, and (2) all or any RTC (ASAM 3.5) services. Findings:  The physician reviewer found that American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.2 criteria for residential withdrawal management services provided on 10/17/21 through 10/24/21 and for Level 3.5 RTC services provided on 10/25/21 through 10/26/21. 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 Level 3.2 withdrawal management, the ASAM criteria guidelines are that the patient is undergoing moderate-to-severe withdrawal but needs 24-hour support because of inadequate home supervision or support structure. In this case, the patient was found attempting to smoke fentanyl residue off of paraphernalia. The patient has demonstrated an inability to complete withdrawal management at a less intensive level of service, as manifested by continued use of other than prescribed drugs or other mind altering substances.  For dimension 1, the patient was managed for opioid withdrawal and sedative-hypnotic use withdrawal with lorazepam and suboxone. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had type 1 diabetes. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was noted as being uncooperative with his assessment. He reported using fentanyl, Xanax, and methamphetamine routinely for several years. He was unable to control impulses to use while in detoxification and was found smoking residue off paraphernalia while at the RTC. The patients mental status was stable enough to permit participation, he demonstrated a repeated inability to control his impulses to use substances, and he was 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 admitted voluntarily for treatment at the request of his mother. The records noted that the patient had minimal insight into the severity of his addiction and that the patient reported that he just needed a quick detoxification. He struggled with participation in the treatment and ultimately left against medical advice. The patient required structured therapy and a 24-hour programmatic milieu because due of the intensity and chronicity of the addictive disorder. He had limited insight and little awareness of the need for continuing care or the existence of his substance use problem and need for treatment, and thus has limited readiness to change.For dimension 5, the patient was started on suboxone. He reported a high level of cravings for fentanyl. This was his first attempt at treatment and medication-assisted treatment. The patient was experiencing addiction symptoms such as drug craving with imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support was indicated to decrease addictive symptoms, such as cravings, to enable the patient to delay immediate gratification and reinforce positive recovery behaviors.For dimension 6, the patient reported using fentanyl and Xanax daily. The records noted legal problems and lack of employment due to his addiction. The patient was unable to cope, for even limited periods of time, outside of 24-hour care and required staff monitoring to learn to cope with problems before being transferred safely to a less intensive setting.Given these findings, the patient met the six ASAM criteria for residential withdrawal management (ASAM 3.2) services and RTC (ASAM 3.5) services. In this patients case, levels of care at issue were in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, (1) residential withdrawal management (ASAM 3.2) services, and (2)  RTC (ASAM 3.5) 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 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.