Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 34-year-old male who was admitted to a residential treatment center (RTC) on 
7/7/22. The patient has requested reimbursement for RTC from 7/26/22 through 8/4/22. The Health 
Insurer has denied this request and reported that the services at issue were not medically necessary 
for the treatment of this patient. This denial is the subject of this appeal and determination. 
The physician reviewer found that per American Society of Addiction Medicine (ASAM) criteria, 
this patient met Level 3.5 criteria for RTC services from 7/26/22 through 8/4/22. 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 withdrawal 
management for opioid withdrawal earlier in his treatment stay. He declined MAT. The patients 
withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had no 
significant medical problems. The patients biomedical problems, if any, were stable and did not 
require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with 
PTSD and MDD. He reported using fentanyl to manage depression about a knee injury and his 
inability to participate in activities that he had previously enjoyed. He reported symptoms of 
depression. He reported using 0.5 grams of fentanyl for two years. He had crashed his motorcycle 
while seeking fentanyl and had an overdose on fentanyl. He reported continued use despite formal 
detoxification  and  RTC  stays.    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. The resulting level 
of dysfunction was of such severity that it precluded participation in treatment in the absence of 
24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted 
voluntarily for treatment after crashing his motorcycle while seeking fentanyl. He reported using 
fentanyl for two years after relapsing in 2019, due to knee injury, following five years of sobriety. 
The patient minimized the severity of his addiction and denied a need for MAT. The patient 
required structured therapy and a 24-hour programmatic milieu to promote treatment progress and 
recovery, because due to the intensity and chronicity of the addictive disorder, he had limited 
insight and little awareness of the need for continuing care or the existence of his substance use 
and need for treatment, and thus had limited readiness to change. For dimension 5, the patient had 
been in a relapse for over two years after using opiate medication for a knee injury. He reported 
using 0.5 grams of fentanyl daily. He had an overdose and a serious motorcycle accident while 
using. He viewed pain as his primary reason for relapse and had not been able to identify other 
relapse triggers. He declined MAT. 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 unable to cope without 
using substances on a daily basis since 2019 and had been unable to work throughout this time due 
to  his  addiction.  He  had  been  in  a  relapse  for  years,  using  substances  alone  in  the  home 
environment. He was developing a plan to move to Arizona and continue treatment there with his 
mothers assistance. The patient was unable to cope, for even limited periods of time, outside of 
24-hour care. He required staff monitoring to learn to cope with problems before being transferred  safely to a less intensive setting. Given these findings, the patient met the six ASAM criteria for 
RTC services provided from 7/26/22 through 8/4/22. Accordingly, the RTC from 7/26/22 through 
8/4/22 was medically necessary for treatment of this patient.