Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any RTC services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 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 was undergoing withdrawal management with buprenorphine and was noted to have withdrawal symptoms of anxiety and restlessness. The patients withdrawal needs were safely managed in level 3.1 setting. For dimension 2, the patient did not have biomedical problems are stable and did not require 24-hour medical or nurse monitoring.For dimension 3, the patient was diagnosed with depression and anxiety disorders. He reported high levels of shame and guilt, and was using opiates to cope with negative emotions. The patient was unable to maintain sobriety in his home environment and relapsed after a 30-day period of abstinence. In the RTC, the patient participated in groups. 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 outside of a structured environment.For dimension 4, the patients current treatment was prompted by a relapse following 30 days of sobriety. The patient reported he was not confident in his ability to remain sober outside of residential treatment. He acknowledged the existence of a substance use problem, identified specific negative consequences of his opioid usage including legal problems, educational problems, relationship problems, and financial problems, and his desire to change. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions had not succeeded at less intensive levels of care. For dimension 5, the patient had been using oxycontin, fentanyl, and cannabis daily. He reported using opioids in an increasing manner since age 24. He had attempted to quit with the support of a sponser but relapsed after 30 days. He lacked coping skills, had ongoing difficulty with feelings of guild and shame, and ongoing cravings despite treatment with buprenorphine. Despite recent, active, participation in treatment at a less intensive level of care the patient continued to use 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 living with his parents. He was unemployed. He was socially isolated with a lack of sober supports other than his parents. The patient lacked social contacts and his social network was characterized by significant social isolation and withdrawal such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, all the RTC services 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.