Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested reimbursement for residential treatment center (RTC) (ASAM Level 3.5) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 withdrawal needs could have been safely managed in a Level 3.5 setting. The patient underwent withdrawal management for benzodiazepine withdrawal earlier in the treatment stay. For dimension 2, the patient does not have significant medical problems. The records indicate that the patients biomedical problems, if any, were 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 has been diagnosed with post-traumatic stress disorder (PTSD), depression, and had substance-induced psychosis. The patient complained of severe insomnia and anxiety. The patient experienced auditory and visual hallucinations up until 10/24/21 and was treated with Haldol. The patient has been taking 14 mg Xanax on a daily basis for the past year and this was mixed with fentanyl.  The patient has history of blackouts, suicidal ideation and suicidal behavior with a gun in the hand within the past year. The patients mental status was assessed as sufficiently stable to permit the patient to participate in therapeutic interventions provided at this level of care and to benefit from treatment. The patients  psychiatric condition was stabilizing. However, despite best efforts, the patient was unable to control use of drugs, with attendant probability of imminent danger. The resulting level of dysfunction was so severe that it precluded the participation in a less structured and intensive level of care. For dimension 4, the patient  admitted voluntarily for treatment after going into withdrawal from Xanax and hallucinating. The patient has been taking 14 mg of Xanax daily for the past year and using Xanax daily since age 16. The patient reported using Xanax mixed with fentanyl and has been unable to work due to the patient's addiction. The patient is also homeless due to the addiction. The provider noted that the patient did not have insight needed in continuing treatment. Because of the intensity and chronicity of the addictive disorder, the patient has limited insight and little awareness of the need for continuing care or the existence of substance use problem and need for treatment, and thus has limited readiness to change. For dimension 5, this is the patients second attempt at treatment. The patient endorsed use of 14 mg of Xanax along with fentanyl for the past year since the patient relapsed after an RTC admission. The patient has been having blackouts once weekly and reports holding a gun to his head earlier this year when feeling suicidal. The patient did not have coping skills to manage remaining sober around others who are drinking or using substances. The patient continued to be depressed and anxious and was focused on just making it through each day such and so was assessed as high risk for relapse if patient were to be discharged. The patients psychiatric condition was stabilizing. However, despite the patient's best efforts, the patient is unable to control 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. The patient's 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 is homeless and was staying with friends who use substances. The patients parents drink excessively. The patient was unemployed due to substance usage. The patient's social group of both friends and family all use alcohol and drugs. The patient did not have a sober support system. The patients social network involves regular users of alcohol and drugs such that the individual patients recovery goals are assessed as unachievable. Given these findings, the patient meets the six ASAM dimensions for Level 3.5 RTC services. Moreover, the RTC services were 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. For these reasons, the RTC (ASAM Level 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.