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 met Level 3.5 criteria for RTC services. The 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 earlier in her treatment stay.  The patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient does not have medical problems. The patients biomedical problems, if any, are stable, and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with schizoaffective disorder-bipolar type although this has been in the setting of ongoing daily methamphetamine usage for several years. The patient has continued to be psychotic during her RTC treatment stay despite high dosages of antipsychotic medications. The patient has engaged in self-harm of cutting her wrists and has endorsed suicidal ideation on several occasions, including while in the RTC. She has been suicidal due to distress from auditory hallucinations. The patient has a history of engaging in risky sexual behaviors due to her substance use disorders. She has continued to be impulsive regarding her treatment and has attempted to get an Uber to leave the facility. The patients mental status has been assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. In addition, the patient has demonstrated repeated inability to control her impulses to use alcohol and other drugs or to engage in antisocial behavior and 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 was admitted for treatment after an admissions to a psychiatric facility on a 5150 hold for suicidal ideation and psychosis. The patient endorsed using daily use of methamphetamine, alcohol, lorazepam, Xanax, and Norco. The patient has been psychotic throughout most of her treatment and has trouble focusing on her addictive disorder. She was undergoing optimization of her psychiatric medication regimen to manage her auditory hallucinations. The patient does not have insight into relapse triggers, and she is in the precontemplative stage of change. Because of the intensity and chronicity of the addictive disorder, she 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  was admitted on a transfer from a psychiatric facility after she was admitted on a 5150 for suicidal ideation and psychosis. The patient was previously treated in a detoxification facility, but she did not participate in follow-up care and began using after her return home. The patient has cut her wrists twice and reportedly has had multiple psychiatric admissions for suicidal ideation and psychosis. She has had difficulty being able to identify relapse triggers due to duration of her usage and severity of her psychiatric disorder. 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 is on disability and lives at home with her child, her mother, and other extended family members. The patients social circle consists of others who use substances and drink. The patient reports obtaining substances from strangers and friends, and she has consistently relapsed when in her home environment. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Based on these findings, the patient meets the six ASAM dimensions for Level 3.5 RTC services. Moreover, the RTC services were and are 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. All told, the RTC services (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 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.