Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services at ASAM Level 3.5. Per 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 patient underwent withdrawal management for opioid withdrawal at another facility. He endorsed significant post-acute-withdrawal syndrome (PAWS) symptoms and was reluctant to accept suboxone maintenance due a history of abusing it in the past. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had a history of a fractured back. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with manic depressive disorder at age 13 and had an extensive history of childhood and more recent trauma and losses. He reported that he started using heroin daily at age 19 and using fentanyl daily since age 20.  He had overdosed three times, requiring hospitalization. Notes reported that the patient had no coping skills, was extremely anxious and depressed, and was reluctant to start suboxone despite his significant PAWS. 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 so severe that it precluded the patient's participation in a less structured and intensive level of care.For dimension 4, the patient was admitted voluntarily for treatment as he had been unable to stop using fentanyl on his own despite trying an intensive outpatient program (IOP) four months earlier. He reported starting daily heroin use at age 19 and had progressed to using fentanyl daily at age 20.  He started an IOP program in July 2021 but relapsed prior to completion. He had a history of abusing suboxone in the community. During this stay, the patient delayed starting suboxone despite having significant PAWS that affected his participation in the treatment program. He was noted as having limited insight into his addiction and need for aftercare. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care. For dimension 5, the patient was reluctant to consider suboxone maintenance during this treatment episode despite significant PAWS that affected his ability to participate in the treatment program.  He reported cravings, anxiety, and joint pain and finally agreed to start suboxone later in his treatment stay. He had previously abused suboxone in the community. He had a history of three overdoses. The patient was experiencing addiction symptoms such as drug craving, posing an 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 had an extensive history of childhood abuse. He had experienced multiple losses including the death of his brother from a heroin overdose. He reported selling drugs since age 15 and his social network consisted of other drug users. The records noted arrests for assault, felony possession, and theft.  He was on leave from work due to operating heavy equipment while using substances. The patient had not been able to cope with his extensive trauma symptoms or with his current stressors without using substances outside of detox or residential treatment settings.  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 RTC services. In this patients case, RTC level of care was 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, RTC services at ASAM Level 3.5 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.