Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for any or all of the residential treatment center (RTC) [American Society of Addiction Medicine (ASAM) 3.5] level of care services. Findings:  The physician reviewer found that ASAM criteria, this patient did not meet 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 was managed for opioid withdrawal earlier in his RTC stay. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient has chronic back pain. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the records noted that the patient was anxious about family conflicts. The patient did not have psychiatric conditions, was not suicidal or homicidal, and participated in group sessions. The patients mental status was stable enough to permit participation, but the records did not indicate that he was unable to control his use of substances or was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrated antisocial behavior patterns, had significant functional deficits of a pervasive nature requiring treatment that is primarily habilitative in focus that were likely to respond to staff interventions, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provided opportunities to promote continuous boundary setting interventions. This criterion was not met.For dimension 4, the patient admitted himself for treatment voluntarily. He actively participated in treatment. The records did not indicate that the patient had limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between substance use, mental health, or life problems and her impaired coping skills and level of functioning, demonstrated passive or active opposition to addressing the severity of his addiction problem, or required structured therapy and a 24 hour programmatic milieu because motivational interventions had not succeeded at less intensive levels of care. The patient did not have a perspective that impaired his ability to make behavior changes without repeated, structured motivational interventions, express little to no interest in changing, or attribute his alcohol, drug or mental health problem to other persons or external events. This criterion was not met. For dimension 5, the patient reported using one gram of fentanyl daily. He reported nine years of sobriety following a previous RTC stay. The patient did not have a history of suicidal or homicidal ideation, suicide attempts or aggression. The patient requested to be tapered off of suboxone and was considering management using vivitrol. The records did not indicate that the patient lacked insight into benefits of continuing care and was therefore not committed to treatment, was unable to control use of substances or experiencing cravings with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, continued to use alcohol despite recent active participation in treatment at a less intensive level of care, or demonstrated a lifetime history of repeated incarceration. This criterion was not met.  For dimension 6, the patient lived in a sober environment with his disabled brother. The records noted conflict with his parents. The records did not indicate that the patient was living in an environment characterized by a moderately high risk of neglect or of endemic substance abuse, or that the patient was unable to cope for even limited periods of time, outside of 24-hour care. The patient did not have a social network including regular users or dealer of substances, or have a social network characterized by significant social isolation and withdrawal, such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. This criterion was not met.Given these findings, the patient did not meet the six ASAM criteria for RTC services. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were and are 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, RTC (ASAM 3.5) level of care services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.