Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 withdrawal management and continued on suboxone. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient does not have active medical problems. The patients biomedical problems, if any, have been stable and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with ADHD and trauma related disorder. He has ongoing difficulty with delaying gratification and impulse control due to his chronic addictive disorder and psychiatric diagnoses. He has impulsively broken rules at the facility, and he has a history of repeated relapses after leaving the structured treatment setting. He also has a history of four opioid overdoses. He has been participating in groups. The patients mental status has been 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. The patient demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction is so severe that it precludes the patients participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted voluntarily due to relapsing on fentanyl within a day after discharge from RTC. The patient reported that he stopped taking suboxone and he was unable to stop using fentanyl on a daily basis. The patient has been using fentanyl daily for three years except for time spent in structured treatment. He has a history of relapse at a lower level of care after discharge from RTC, and it is not reported whether he attended recommended programming. The patient is in precontemplative stage of change as evidenced by using cannabis in facility and stopping suboxone after discharge from prior RTC stay. The patient requires 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 and such interventions are assessed as not likely to succeed at a less intensive level of care.For dimension 5, the patient has been using fentanyl on a daily basis for the past three years except when in treatment facilities. His longest sobriety was eight months in a sober living facility. He has multiple prior treatment episodes. The patient underwent detoxification and then he continued on suboxone for medication assisted treatment to help with opioid cravings. He has a history of four prior opioid overdoses. The patient is experiencing addiction symptoms such as drug craving. This situation poses an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease addictive symptoms that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors. For dimension 6, the patient is unemployed and did not complete high school. The patient has a criminal history with a recent incarceration. The patient was previously homeless but was most recently living with his mother. Most of his social network are drug dealers and other users. The patients  social network includes regular users of alcohol and other drugs such that recovery goals are assessed as unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Moreover, the RTC services are 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. Therefore, the RTC services for mental health and substance use disorder treatment, specifically ASAM level 3.5, 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 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.