Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) (ASAM 3.5) level of care.Findings:  The physician reviewer found that 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 management for opioid withdrawal and had a suboxone dosage adjustment on 11/16/21. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2 the patient did not have biomedical problems and did not require 24-hour medical or nurse monitoring.For dimension 3, the patient has major depressive disorder. He reported using up to three grams of fentanyl and one gram of methamphetamine daily. The patient had relapsed since being released from prison despite being on probation which required participation in treatment. He reported a history of three or four overdoses. The patient was planning on returning to his hometown, where his life revolved around using drugs, despite a history of multiple relapses after leaving treatment. 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. The patient reported using substances, including opiates and methamphetamine, for 15 years. He had relapsed shortly after being released from prison despite being on probation, which required participation in a drug treatment program. The records noted that the patient struggled to participate in treatment and was unable to identify relapse triggers or specific coping skills. He had relapsed multiple times upon returning to his hometown due to having numerous drug contacts there, yet insisted on returning there, denying he would be at risk for relapse. Due to the intensity and chronicity of the addictive disorder, the patient 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 was started on Suboxone but continued to endorse symptoms of withdrawal. The patients Suboxone dosage was adjusted while at the RTC. The patient was experiencing addiction symptoms such as drug craving, and the situation posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support was indicated to decrease addictive symptoms, such as cravings, to enable the patient to delay immediate gratification and reinforce positive recovery behaviors.For dimension 6, the patient was unable to cope without using substances outside of a controlled environment. The records noted that the patient was unemployed and had lost a relationship with the mother of his three-year-old daughter due to his addiction. He was on probation and required to participate in drug treatment, but had relapsed upon being released from prison. 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 with problems before being transferred safely to a less intensive setting.Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, RTC (ASAM 3.5) level of care was 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.