Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services provided at The Lakes Treatment Center.Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.1 or Level 3.5 criteria for RTC. 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 with benzodiazepines for detoxification and had symptoms of withdrawal, including anxiety and tremors. The patients withdrawal needs were safely managed in a level 3.1 setting. The patient met this criteria.For dimension 2, the patient had issues with constipation. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. The patient met this criteria.For dimension 3, the patient had a diagnosis of anxiety disorder. He had been managed on clonazepam in the community for the past 20 years. He did not endorse suicidal or homicidal ideation and was able to perform activities of daily living. He participated in group sessions. The records did not reflect that the patients co-occurring psychiatric condition being addressed concurrently through appropriate psychiatric services. While the patients mental status was stable enough to permit participation, he did not demonstrate imminent likelihood of relapse with dangerous consequences outside of a structured environment, or sufficiently severe symptoms and functional limitations such that he was assessed as not likely to maintain mental stability and abstinence if treatment as provided in a nonresidential setting, or an inability to maintain stable behavior over a 24-hour period without the structure and support of a 24-hour setting. The patient did not meet this criterion.For dimension 4, the patient admitted himself for treatment of his alcohol use disorder. He expressed a desire to be abstinent and felt that his health was deteriorating. The patient recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. The patient met this criteria. For dimension 5, the patient reported drinking a fifth of vodka daily for the past seven to ten years. This was his third attempt at treatment. He had insight into his relapse triggers and was knowledgeable of coping skills. The patient was not at imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences, at risk of relapse in a less structured level of care due to an inability to consistently address addiction and mental disorder, or in need of staff support to maintain engagement in his recovery program while transitioning to life in the community. The patient did not meet this criteria.For dimension 6, the patient lived alone and was self-employed. He reported financial stress and wanted to change careers. He reported having a social support network. While the patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities, he did not live in an environment characterized by repetition of physical or emotional abuse such that recovery was unachievable or in an environment highly invested in alcohol. He did not lack social contacts or a social network, had sufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment, and was not in danger of victimization. The patient did not meet this criteria.Given these findings, the patient did not meet ASAM criteria dimensions 3, 5, and 6 for RTC services. Accordingly, the RTC services were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.