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) services. Findings:  The physician reviewer found that Per the 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 reported multiple withdrawal symptoms and cravings. Based on The available records, the patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient has history of neurosyphilis and chronic pain. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with PTSD, ADHD, and he was also assessed as having neurocognitive impairment from years of heavy substance usage that has affected his ability to regulate his affect and behaviors. The patient has history of seizures and blackouts related to his substance usage. The patient has severely injured himself due to his intravenous substance use. The patient continued to ask for stimulant medication in the RTC despite being told that this was not allowed. The patients mental status was assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. In addition, the patient has demonstrated repeated inability to control his impulses to use alcohol and other drugs or to engage in antisocial behavior and is in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction is of such severity that it precludes 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 to RTC voluntarily for treatment after walking around homeless for two days. The patient endorsed a history of intravenous amphetamines use on a daily basis for five years. The patient has not experienced any days of sobriety since 2011. The patient struggled with following recommendations in the program and sought stimulant medications. Because of the intensity and chronicity of the addictive disorder, he has limited insight and little awareness of the need for continuing care or the existence of her substance use and need for treatment, and thus has limited readiness to change. For dimension 5, this patient has been in a relapse since 2011. He has been using intravenous methamphetamine daily for five years. The patient did not consider stimulants as a relapse trigger and he continued to request medications during his stay. He also did not see being around his girlfriend who uses substances as being a relapse trigger. He has history of blackouts and seizures secondary to his intravenous substance usage. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment. The patients 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 has not been able to cope without using substances on a daily basis for the past five years. The patients life has been built around substances and his social life consists of other users. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions to support an indication for the RTC ASAM 3.5 services. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the RTC (ASAM 3.5) level of care 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 with subspecialty certification in in addiction medicine 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.