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) (ASAM 3.5) level of care. Findings:  The physician reviewer found that 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. Of note, as this patient was 17 upon admission to the RTC, adolescent level of care criteria apply. For adolescents to meet medical necessity for Level 3.5, they need meet only the specifications in two of the six dimensions. For dimension 1, the patient has a history of cannabis use disorder and cannabis hyperemesis syndrome. He had been vomiting daily for the past two months prior to treatment. The patient exhibited symptoms of moderate-to-severe withdrawal from cannabis involving irritability and general malaise such that the patient needs 24-hour secure placement and increased treatment intensity to support the adolescents ability to tolerate symptoms, support engagement in treatment, and bolster external supports.For dimension 2, the patient has a history cannabis hyperemesis syndrome which recurred two months ago, requiring emergency room visits and medication for vomiting.  The patients biomedical conditions distract from recovery efforts and require residential supervision to ensure their adequate treatment.For dimension 3, the patient has been diagnosed with posttraumatic stress disorder (PTSD), panic disorder, and gaming disorder. He reports using cannabis daily throughout most of high school and is socially isolated except for friends with whom he uses cannabis. The patient is noted as failing academically. He plays video games for 12 hours at a time. The patient has significant impairments, with moderate-to-severe symptoms, that impair his ability to function in social and school settings.For dimension 4, the patient was admitted voluntarily for treatment due to two months of daily vomiting from cannabis hyperemesis syndrome. He reported problematic cannabis use throughout high school. He expressed wanting treatment but requested to leave against medical advice at age 18. The records noted conflicts with other teenagers and that the patient reported that he felt that he did not require residential treatment. The patient demonstrates passive or active opposition to addressing the severity of his mental or addiction problem, or does not recognize the need for treatment. Such continued substance use or inability to follow through with mental health treatment poses a danger of harm to self or others. However, assessment indicates that treatment interventions available at Level 3.5 may increase the patients degree of readiness to change.For dimension 5, the patient has been heavily using cannabis daily through most of high school. He reported two periods of abstinence due to cannabis hyperemesis syndrome but relapsed after experiencing a significant loss, his close friend's suicide. The patient denies urges to use while at the RTC. The patient does not meet this the criteria for this dimension.For dimension 6, the patient is in high school and lives with his parents. He reports that his friend group all use cannabis heavily. His older brother uses cannabis along with other substances. The patient has a family member with active substance use disorder, and substance use is endemic in his broader social network so that recovery goals are assessed as unachievable without residential treatment.Given these findings, the patient meets five the six ASAM criteria for RTC services. For Level 3.5 RTC treatment for adolescents, criteria in two of the six dimensions must be met. 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, RTC (ASAM 3.5) level of care was and is 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 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.