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 3.5). Per the American Society of Addiction Medicine (ASAM) criteria this patient meets Level 3.5 criteria for RTC services. The 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 for opioid withdrawal and has required suboxone dosage adjustments throughout his treatment stay. The patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient has history of seizures and migraines. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has a lengthy history of opioid use disorder. Most recently, he endorses use of 1 mg of fentanyl daily along with 16 mg of Subutex. The patient also uses methamphetamine daily and Xanax once or twice weekly. The patient uses substances while driving and he sustained a blackout that caused a motor vehicle accident one month ago. He has sustained three overdoses that required Narcan within the past 15 months. He learned that his best friend overdosed and died while patient was in the facility. He is noted to lack coping skills for managing loss without use of substances. 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. In addition, the patient has demonstrated repeated inability to control his impulses to use alcohol and other drugs or to engage in antisocial behavior and is in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted voluntarily for treatment as he has been unable to stop using substances on his own and combining Subutex and fentanyl daily. The patient previously has been treated in multiple RTC treatments but he has not followed through with his discharge instructions. The provider noted that the patient has little understanding of his drug usage and the severe consequences of his ongoing usage. The patient has continued to use substances despite three overdoses requiring Narcan and a seizure disorder that is aggravated by his methamphetamine usage. Because of the intensity and chronicity of the addictive disorder, he has limited insight and little awareness of the need for continuing care or the existence of her substance use and need for treatment, and thus has limited readiness to change. For dimension 5, the patient has been using Subutex along with fentanyl on a daily basis in addition to methamphetamine and Xanax. He has been in treatment numerous times. The patient poses a danger to himself given the three overdoses requiring Narcan in the past 15 months. The patient is also a danger to others since he drives while under the influence of substances and he has sustained a blackout that caused an accident within a month of this admission. The providers notes indicate that the patient has some insight into relapse triggers but he has no skills to manage these triggers without using substances. The patient lacks insight into the severity of his substance use disorder. 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 homeless due to his addiction. The patients social network consists of other drug users. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions to support RTC (ASAM 3.5) level of care services provided from 6/1/22 forward. Moreover, the RTC services were and 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. All told, the RTC services (ASAM 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 * 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.