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, specifically ASAM level 3.5. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services early January 2022 and forward. 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 management for complicated withdrawal upon initial admission and required management at an inpatient hospital level of care. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient is 32 weeks pregnant. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient has diagnoses including generalized anxiety disorder and OCD. She reported using Xanax, fentanyl, and methamphetamine throughout her pregnancy. The records noted that she continued to be very impulsive, smuggled substances into the RTC, and had her boyfriend bring drugs into the RTC in a baby blanket. The ongoing usage of Xanax, opioids, and amphetamine during pregnancy present a risk to both the fetus and the patient. The patients mental status is stable enough to permit participation, she demonstrates a repeated inability to control his impulses to use substances, and she is in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program.For dimension 4, the patient reported using half a gram of methamphetamine, two pills of Xanax, and one and a half grams to two grams of fentanyl and heroin daily since, continuing usage since learning of her pregnancy, now at 32 weeks gestation. The patient reported using opioids since age 18 and methamphetamine since age 21. She appears ambivalent about treatment as evidenced by her smuggling drugs into and asking her boyfriend to smuggle drugs into the RTC. She reports a desire to return to a home environment that includes drug users and dealers. Due to 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 her substance use and need for treatment, and thus has limited readiness to change.For dimension 5, the patient relapsed following a one month admission at an RTC. She reported using methamphetamine, fentanyl, and Xanax daily despite being pregnant, now at 32 weeks gestation. The patient reports ongoing cravings despite being on suboxone maintenance. She reports that she wants to return to her boyfriend, who uses and sells drugs, and does not seem to recognize that this would be a trigger for relapse. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. Her continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support.For dimension 6, the patient has been living in a mobile home with her sister, who uses substances, and with her boyfriend, who uses and deals substances. Her social circle consists of others who deal substances. She is unemployed and pregnant. The patient has consistently relapsed when in her home environment. The patient's social network includes regular users and substances 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 criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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, specifically ASAM level 3.5, 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 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.