Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center services (equivalent to ASAM 3.5).At issue in this case is whether continued Residential Treatment Center (RTC) services (equivalent to ASAM 3.5) and services at issue were, and are, medically necessary as defined in Health and Safety Code section 1374.72(a)(3)(A) to treat the enrollees mental health or substance use disorder.American Society of Addiction Medicine (ASAM) criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient underwent withdrawal management earlier in his treatment stay. The patients withdrawal needs could therefore be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. The patient has a history of seizure disorder. The patients biomedical problems, if any, were stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient has been diagnosed with schizoaffective disorder and generalized anxiety disorder. He complains of ongoing auditory hallucinations and intermittent suicidal ideation. He was noted to be delusional with paranoid delusions. He has a history of blackouts and a suicide attempt. The patient was noted to be impulsive and at times was directed to do things that his voices told him to do. He was preoccupied with delusional content such as having a chip in his brain or not wanting to disclose his plan for suicide at times during his treatment stay. He has had numerous attempts at treatment with relapse shortly after discharge due to his lack of impulse control. The patients mental status permitted participation. The patient also demonstrated an inability to control his impulses or to engage in antisocial behavior and has been in imminent danger of relapse. The patient also demonstrates antisocial behavior patterns which prevent positive change and preclude participation in a less structured environment.For dimension 4 - Readiness to Change. The patient was admitted voluntarily for treatment after a 4-day binge on methamphetamine. He had been smoking 5 grams of methamphetamine daily for the past 6 months and has been using methamphetamine since the age of 14. He has continued to use these drugs despite being kicked out of his parents' house and being homeless. The patient has developed severe, persistent, auditory hallucinations and delusions. He reported that `living on the streets and using helps a person cope better.` The patient felt that he did well at his mothers home despite persistently using while there due to a neighbor offering him methamphetamine. The patient meets the subcriteria of, `Despite experiencing serious consequences or effects of the addictive disorder, because of the intensity of the addictive disorder, the patient has marked difficulty in understanding the relationship between his substance use, addiction, mental health, or life problems and his impaired coping skills and level of functioning.`For dimension 5 - Relapse, Continued use, or Continued Problem Potential. This patient has had multiple attempts at treatment. He has been smoking 5 grams of methamphetamine daily for the past 6 months and using consistently since the age of 14. He is unemployed and has a troubled relationship with his parents due to his substance usage, and he has been kicked out of their home and has been homeless for the past 6 months. The patient was noted to have little awareness of his relapse triggers and to have limited clean time outside of a treatment facility. The patient reported that he felt that his mother's house was a place that he could be sober, and he was noted as stating that `using helps you cope better.` Records indicate that the patient did not recognize that his mother's neighbor, who had offered him free methamphetamine, had contributed to his multiple relapses. The patient voiced that he could best maintain sobriety by returning to his mothers house. The patient has a history of a suicide attempt, and he continued to voice auditory hallucinations and intermittent suicidal ideation. The patient meets the subcriteria of requiring 24-hour monitoring and structured support. He does not recognize his relapse triggers and he has little awareness of his need for continuing care and is therefore not committed to treatment. His continued openness to substance use poses an imminent danger of harm to himself or others in the absence of 24-hour monitoring and structured support.For dimension 6 - Recovery Environment. The patient is homeless and stays with other people with whom he uses drugs. He is unemployed due to his substance usage. He does not have a sober support system. He has been hesitant to consider going to a sober living environment, as he believes that staying with a friend who uses methamphetamine is a reasonable alternative. The patient meets the subcriteria of having a social network that involves regular users of alcohol and drugs such that his recovery goals would be assessed as unachievable.Using the ASAM level 3.5 criteria worksheet, the patient meets all six criteria for medical necessity and therefore qualifies for continued ASAM Level 3.5 treatment as well as the services in issue. The patients scores under the six ASAM criteria take into account the specific needs of the patient for the purpose of treating their illness and its symptoms. The ASAM criteria for determining the appropriate level of care is consistent with generally accepted standards of mental health, and it provides determinations that are clinically appropriate in terms of type, frequency, extent, site, and duration. The ASAM criteria are also free from consideration of 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, continued RTC services (equivalent to ASAM 3.5) and the services in issue, were, and are, medically necessary to treat the patients mental health or substance use disorder, as defined in Health and Safety Code section 1374.72(a)(3)(A).Final Result: The reviewer determined that the services at issue and requested services were, and are, medically necessary to treat the patients mental health or substance use disorder, as defined in Health and Safety Code section 1374.72(a)(3)(A). 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.