Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with opioid use disorder, opioid dependence with withdrawal, opioid dependence with opioid-induced psychotic disorder, anxiety disorder, post-traumatic stress disorder, major depressive disorder, cocaine use disorder, and sedative, hypnotic, or anxiolytic use disorder and dependence with withdrawal. The patient was admitted to a residential treatment center. The patient was noted to have a history of heroin, alcohol, and cannabis use. The patient denied suicidal ideation and a clinical opiate withdrawal scale (COWS) score was rated as seven, consistent with mild withdrawal. The patient reported feeling excited. The patients clinical institute withdrawal assessment for alcohol (CIWA) score was rated as three, and the patient was reported to have a sad mood with limited judgment. The patient has requested reimbursement for residential treatment center level of care services that were provided. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether residential treatment center level of care services that were provided were medically necessary for the treatment of the patients medical condition. The American Society of Addiction Medicine (ASAM) criteria is the most widely used and comprehensive set of guidelines for placement, continued stay, and transfer/discharge of patients with addiction and co-occurring conditions. According to the ASAM 3.5 criteria, an adult must meet six out of six criteria in order to support residential treatment center (RTC) level of care. For acute intoxication and/or withdrawal potential, the patients COWS and CIWA scores were in the mild withdrawal range. For biomedical conditions/complications, there was no documentation of biomedical conditions that placed the patient at risk during the RTC treatment period. For emotional/behavioral/cognitive conditions and complications, the patient was diagnosed with depression with suicidal ideation. Of note, during RTC treatment, she indicated an improving mood and was participating in therapy with minimal difficulties. For readiness to change, the patient did not report cravings. For relapse/continued use/continued problem potential, there was no documentation of opposition to addressing her substance use problem. For recovery environment, there was no documentation of problems in the patients recovery environment. The medical evidence does not support the services at issue in this clinical setting. Therefore, residential treatment center level of care services that were provided from were not medically necessary for the treatment of the patient. Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.