Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the residential treatment center (RTC)  services (ASAM Level 3.5). Per 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 underwent withdrawal management earlier during his RTC stay. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had a diagnosis of sedative-hypnotic use disorder. He reported taking up to 3 mg of Xanax with concomitant prescription opioid usage. There was a high risk of accidental overdose with prescription benzodiazepine and opioid usage, especially given the patients underlying OSA requiring CPAP therapy. The patient reported that he had been unable to reduce substance use on his own due to insomnia and anxiety. The records noted that the patient participated in groups. He was noted to have difficulty with his treatment, reporting that he was unable to accept treatment and that it was too much for him. 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. For dimension 4, the patient was admitted voluntarily for longstanding substance use problems involving prescription Xanax, prescription opioids, and cocaine. The records noted that the patient minimized and did not take full responsibility for his substance use, blaming others. He was openly negative about treatment. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery because of the intensity and chronicity of his addictive disorder, which resulted in his limited insight and awareness of the need for continuing care or the existence of his substance use and need for treatment, and limited readiness to change. For dimension 5, the patient reported using up to 3 mg of Xanax for ten years, along with prescription Dilaudid following surgery the month prior. The combination of benzodiazepine and opioids in the setting of OSA placed him at high risk for an unintentional overdose. The patient reported using substances for over twenty years. He reported that he was seeking treatment due to wanting to please his wife and children. The records noted that the patient was negative about treatment, and fearful of the damage already done. The patient did not recognize relapse triggers aside from the physical symptoms of insomnia and pain. He did not feel that he had a substance use problem requiring ongoing treatment after discharge. The patient was at high risk for relapse, given his post-acute withdrawal syndrome (PAWS) symptoms from Xanax. The patient did not recognize relapse triggers, lacked insight into the benefits of continuing care, was not committed to treatment, and 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 lived with his wife, who drank wine. He did not have an outside support system and was dependent on his wife for his emotional needs. He has been unable to reduce his Xanax use as an outpatient due to severe insomnia and anxiety. The patient was unable to cope, for even limited periods of time, outside of 24-hour care and required staff monitoring to learn to cope before being transferred to a less intensive setting.Given these findings, the patient met the six ASAM criteria for RTC services. Therefore, RTC services (ASAM Level 3.5) received were medically necessary for the 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.