Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for any or all the RTC services provided by The Lakes Treatment Center.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 was placed on a Librium taper for benzodiazepine withdrawal and continued to have withdrawal symptoms. The patients withdrawal needs can be safely managed in level 3.5 setting. For dimension 2, the patients does not have active medical problems. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had diagnoses of schizophrenia spectrum, panic disorder, and anxiety disorder. He had an involuntarily psychiatric admission for four days. He continued to use Xanax. He had ongoing deficits in hygiene and struggled to focus during group therapies. The patients mental status was and is stable enough to permit participation, and he demonstrates significant functional deficits that are sufficiently severe that he is not likely to maintain mental stability or abstinence outside of treatment provided in a residential setting. For dimension 4, the patient reported that his parents had forced his admission to the RTC. He reported not feeling that he had a substance abuse problem. The records noted that the patient did not take responsibility for his ongoing substance use disorder, repeatedly asked what he needed to do to leave, and had difficulty focusing on his treatment plan. This is his first attempt at treatment. The patient's perspective impairs his ability to make behavior changes absent structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery. For dimension 5, the patient has been using Xanax daily for the past year. He reported using edible cannabis and wax. He reported a history of up to ten blackouts. This is his first attempt at treatment. The patient had a history of involuntary psychiatric admission, and repeatedly requested discharge despite not completing his treatment goals. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. His continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support.For dimension 6, the patient is single and unemployed. He lives with his parents, whom he reports as being emotionally abusive, and have their own prescription of  Xanax. The patients environment is characterized by a moderately high risk of repetition of emotional abuse such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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 services provided by The Lakes Treatment Center were and are medically necessary were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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.