Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for all or any residential treatment center (RTC) (ASAM 3.1) level of care. 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 treated for opioid withdrawal with suboxone earlier in his treatment stay. The patients withdrawal needs were safely managed in a Level 3.1 setting. For dimension 2, the patient does not have any active medical problems. The patients biomedical problems are stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported symptoms of depression and of isolating. The records did not note that the patient was suicidal. The patient reported relapsing on fentanyl while employed at a recover center driving clients to appointments. The records noted a history of driving under the influence of alcohol and fentanyl, posing a potential harm to himself and others. He participated in group sessions. The patients mental status was stable enough to permit participation, and his psychiatric condition is stable as evidenced by both of the following: (1) the patient's anxiety and depression may be related to substance use problems or to a stable co-occurring emotional, behavioral, or cognitive condition, with imminent likelihood of relapse with dangerous consequences outside of a structured environment, and (2) the patient is assessed as not posing a risk to self or others.For dimension 4, the patient admitted himself for treatment voluntarily due to relapsing on fentanyl while working at a recovery center. He was able to acknowledge negative consequences of his substance use including loss of employment and financial problems. The patient acknowledged the existence of a substance use problem, recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change, and was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5, the patient reported snorting up to five 30 mg oxycodone tablets along with up to seven tablets of fentanyl daily for the past three to five years. He reported a five-month period of abstinence but had relapsed. He was able to recognize risk of relapse but was unable to employ any coping skills or make any changes to prevent a relapse. The patient endorsed using fentanyl and alcohol while driving in the community and while working. The patient demonstrated limited coping skills to address relapse triggers and urge and was thus in imminent danger of relapse with dangerous behavioral consequences, requiring 24-hour structure to help him apply recovery and coping skills.For dimension 6, the patient was living in a sober living environment (SLE) and working at a recovery center, surrounded by clients who were relapsing and using, resulting in his own relapse on fentanyl. He does not appear to have a sober social support network and is socially isolated. The records note that he has little knowledge of coping skills. The patient was able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities. Continued exposure to the patients work or living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of the 24-hour supportive environment.Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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, the RTC (ASAM 3.1) level of care provided was and is 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 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.