Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement 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. 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 reported some continued post-acute withdrawal symptoms. The patient was initially treated for symptoms of withdrawal. He endorsed abuse of opiates, alcohol, and cannabis as well as multiple other substances in the past. He continued to report post-acute withdrawal symptoms throughout this RTC admission. The patients withdrawal needs could have been met in a Level 3.5 setting. For dimension 2, the patient had complaints of pain in his arm and hip on presentation. He has no reported active comorbid medical issues. He was medically stable. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient reported a history of grief and past trauma. He has a history of significant issues with family conflicts. He was separated from his wife, living with an aunt, and he was distressed about his lack of contact with his children. The patient refused to see a psychiatrist but did actively participate in therapy programming over the course of the RTC admission. He was diagnosed with PTSD in addition to his substance use disorder diagnoses. The documentation supports the need for structure to focus on recovery. The patients mental status was 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. The patient demonstrated a repeated inability to control his impulses to use alcohol and other drugs and was in imminent danger of relapse, with attendant likelihood of harm to self or others, or property. The resulting level of dysfunction was of such severity that it precluded participation in treatment in the absence of a the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was initially ambivalent about coming to treatment. He acknowledged having a substance use disorder since he graduated from wanting drugs to needing them to function. He expressed feelings of ambivalence about seeking treatment, stating that one of the barriers to recovery was that he likes using substances while having a good time. The patient required structured therapy in a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care and such interventions were assessed as not likely to succeed at a less intensive level of care. For dimension 5, the patient indicated that he was sober from opiates for a period of time in the past, but he then indicated that he stayed sober by using kratom during his time off of opiates. He reported a history of several prior episodes of treatment followed by relapses. The patient continued to abuse substances and alcohol despite legal issues, separation from his wife, and multiple other consequences. He demonstrated limited recognition of skills needed to prevent continued use with imminently dangerous consequences. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment. His continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient was separated from his wife and staying with an aunt. His family was supportive of his efforts at treatment, as they participated in an intervention prior to his decision to come to treatment. He was on leave from his job to participate in treatment. The patient was unable to cope, even for limited periods of time, outside of 24-hour care. He needed staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Given these findings, the patient met the six ASAM dimensions for RTC services. The RTC services were medically necessary and 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 or benefit of the patient or provider. For these reasons, the mental health RTC services were medically necessary to treat the patients mental health or substance use disorder as defined in Health and Safety code section 1374.72(a)(3)(A).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 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.