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. 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 had an extended detoxification period and was stabilized on suboxone. The patients withdrawal needs were safely managed in level 3.5 setting. For dimension 2, the patients does not have active medical problems. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with major depressive disorder while at the RTC and started on medication. He had a criminal history and was noted to have difficulty with authority and lacks insight into his emotional state and psychiatric diagnosis. The patients mental status was stable enough to permit participation. He demonstrated a repeated inability to control his impulses to use substances, and he was in imminent danger of relapse with attendant likelihood of harm to self in the absence of structured 24-hour support. For dimension 4, the patient admitted himself for treatment following two overdoses requiring medical treatment. The records noted that the patient was isolative and withdrawn, and had difficulty actively participating in groups. This is his first attempt at treatment. The patient's perspective impairs his ability to make behavior changes without structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery.For dimension 5, the patient has been using opioids daily for the past three to five years. This is his first attempt at treatment. He reported ongoing cravings for opioids despite currently being managed on suboxone. He has history of two overdoses on Xanax and oxycontin/fentanyl requiring medical attention, with the most recent overdose resulting in intubation. The patient is experiencing addiction symptoms such as drug craving, posing imminent serious consequences and high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient is single, unemployed, and currently on parole. He lives with his mother and with his brother, who uses alcohol socially. He does not have a sobor support system and is otherwise socially isolated. The patient is unable to cope, for even limited periods of time, outside of 24-hour care such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient met 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, the RTC services were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 internal medicine with sub-specialty certifications in medical oncology and hematology 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.