Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services provided by Authentic Recovery, LLC at Level 3.5 ASAM. 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 management for opioid withdrawal, sedative-hypnotic use disorder, and alcohol use disorder. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient has a history of pulmonary embolism. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported a history of bipolar disorder and had a diagnosis of major depressive disorder. He reported using five grams of fentanyl daily for the past nine months. He had a history of overdoses. The records noted that in the middle of his treatment stay, he left the RTC for five hours and relapsed. 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. For dimension 4, the patient was admitted voluntarily for treatment following being held at gunpoint due to his substance use. The records noted that the patient struggled to fully engage in treatment and was not initially willing to be managed on Vivitrol maintenance. The patient reported using fentanyl and alcohol daily since his last relapse nine months ago, along with benzodiazepines and methamphetamine. He had a history of overdoses. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, due limited insight and little awareness of the need for continuing care as a result of the intensity and chronicity of his addictive disorder.For dimension 5, the patient had a history treatment attempts and relapses, including a relapse following detoxification. He had a history of overdoses. While the patients psychiatric condition was stabilizing, despite his best efforts. The patient was unable to control his use of alcohol or drugs, with imminent serious consequences and was at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient was being discharged to a SLE as he was homeless and unable to maintain sobriety otherwise. The patient is unemployed. He is socially isolated except for one friend and does not have a family support system. He has not been able to cope without using substances outside of detoxification or RTC. The patient is 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 meets 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 provided by Authentic Recovery, LLC at Level 3.5 ASAM 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.