Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. 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 patients withdrawal was safely managed at Level 3.5 with suboxone. For dimension 2, the patients biomedical conditions were not severe enough to warrant inpatient treatment but were sufficient to distract from treatment or recovery efforts. Her problem required medical monitoring, which was provided by the program. The patient engaged in high-risk sexual behavior due to the loss of inhibition secondary to her substance use disorder. The patient reported that she was able to control her bulimia through substance use. For dimension 3, the patients mental status was sufficient to permit her participation in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient demonstrated repeated inability to control her impulses to use alcohol and drugs, with attendant probability of imminent danger, and high-risk sexual behaviors, and as such, these behaviors place her at risk of imminent danger. 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. In addition, the risky combination of drugs and alcohol, place her at risk of medical complications. For dimension 4, the patients perspective impaired her ability to make behavioral changes without repeated, structured, clinically directed motivational interventions, which would enable her to develop insight into the role she plays in her substance use disorder and to empower her to make behavioral changes, which can only be delivered in a 24-hour milieu. The patient demonstrated limited insight after prior detoxifications when she refused longer-term treatment. The patients chances of sobriety without Level 3.5 RTC were unlikely given her risk of relapse and accidental overdose on opioids following a relatively short period of sobriety from opiates. She was discharged on suboxone. For dimension 5, the patient experienced addiction symptoms including drug craving, insufficient ability to postpone immediate gratification, and other drug-seeking behaviors. The situation posed an imminent danger of harm to herself as evidenced by high-risk behaviors and serious medical consequences of continued use, in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support with suboxone and Zoloft was appropriate to decrease psychiatric and addictive symptoms that would enable the patient to decrease addictive symptoms, such as cravings and reinforce positive recovery behaviors. For dimension 6, the patients social network involved her ex-boyfriend, who is a regular substance user, such that recovery goals were assessed as unachievable at a less intensive level of care. The patient was unable to cope, for even limited periods of time outside of 24-hour care. She needed staff monitoring to cope with dealing with her recovery environment before transfer to a less intensive care setting. Based on these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC 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 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.