Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) (ASAM Level 3.5) services. 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 management for opioid withdrawal and reported ongoing withdrawal symptoms, including tremors. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had a cerebrovascular accident (CVA) following an overdose of a substance and has cognitive symptoms as a result. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with a panic disorder and had a history of CVA and overdose. They reported using fentanyl on a daily basis. They reported relapsing immediately after being discharged from a physical rehabilitation stay after the CVA. The patients mental status was stable enough to permit participation. They demonstrated a repeated inability to control their impulses to use substances, and they were in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient admitted voluntarily for treatment, but the records noted little motivation to engage in treatment. They reported using heroin and fentanyl daily. They had a history of overdoses, including one resulting in a stroke. They relapsed immediately when not in the residential setting, including after being released from a residential physical rehabilitation program. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care. For dimension 5, the patient had a history of prior attempts at treatment, relapsing each time when discharged from residential care. 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 had been living with family in an unhealthy and enmeshed relationship. The patient was unemployed. They were socially isolated, did not have a sober support system, and were unable to cope without using substances outside of residential care. 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, the RTC (ASAM Level 3.5) 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.