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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.1 or 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 treated with benzodiazepines for withdrawal management early in her treatment stay. The patients withdrawal needs could have been safely managed in a Level 3.1 setting. For dimension 2, the patient does not have any medical problems. Biomedical problems were stable and did not require medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient complained of anxiety and passive suicidal ideation. She was diagnosed with anxiety and depression. The patients activities of daily living were intact. She participated in groups. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. However, the patient did not meet any of the additional criteria for this dimension, including imminent likelihood of relapse with dangerous consequences outside of a structured environment, sufficiently severe symptoms and functional limitations that the patient was assessed as not likely to maintain mental stability and abstinence if treatment was provided in a nonresidential setting, or demonstrated an inability to maintain stable behavior over a 24-hour period without the structure and support of a 24-hour setting. Lastly, there is no documentation of this patients co-occurring psychiatric condition being addressed concurrently through appropriate psychiatric services. Given these findings, the patient did not meet the requirements for this dimension. For dimension 4, the patient admitted herself for treatment of her alcohol use disorder as she was experiencing many negative consequences from her alcohol use disorder. She expressed a desire to become abstinent and she was able to identify negative consequences of alcohol usage, including occupational problems and relationship problems. The patient acknowledged the existence of psychiatric condition and a substance use problem. The patient recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient endorsed drinking one pint of vodka plus one to two bottles of wine on a daily basis for the past two years. This is her first attempt at detoxification and residential treatment. She demonstrated insight into relapse triggers and was willing to make significant changes in her life to maintain sobriety. The patient did not meet any of the criteria for this dimension since she was not in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences, she was not at risk of relapse in a less structured level of care, and she did not require staff support to maintain engagement in the recovery program while transitioning to life in the community. Given these findings, the patient did not meet the requirements for this dimension. For dimension 6, the patient was living with her husband, whom she reported was abusive. She did have a social support network and her parents were described as supportive. By the first day of denial, the patient was stable for discharge to her parents home or a sober living environment. 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. However, the patient did not meet any of the other criteria since the patient was not living in an environment characterized by repetition of physical or emotional abuse such that the patient was assessed as being unable to achieve or maintain recovery at a less intensive level of care, lacked social contacts and social network was characterized by significant social isolation and withdrawal, living environment highly invested in alcohol, or had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient did not meet the requirements for this dimension. ASAM requires adult patients to meet all six dimensions for RTC services. This patient did not meet the requirements for dimensions 3, 5, and 6. Therefore, the RTC services were not medically necessary for 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 with subspecialty certification in addiction medicine 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.