Appeal type: Medical Necessity
Decision: Overturned 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 met Level 3.5 criteria for clinically managed high-intensity residential 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. Given the patients need for detoxification in a controlled environment, she has shown the potential for medically complicated withdrawal if she were to relapse. When previously withdrawing, she has experienced irritability, anxiety, vomiting, and diaphoresis. She has been unable to control her alcohol use without 24-hour support. This patient was at high risk for alcohol and benzodiazepine withdrawal. She had been drinking daily for two months with morning drinking and extended periods of blackouts. When she presented for care, she was intoxicated with a blood alcohol concentration (BAC) of 0.133. Given her daily benzodiazepine usage, she was at risk for a complicated and protracted withdrawal course. The patient has migraine headaches rated as mild. The patient has a 20-year history of anxiety treated with daily Xanax. She has been noncompliant with other medications of Paxil and Wellbutrin. She uses alcohol to manage the stressors in her life. The patient was described as willing but not yet ready or able for meaningful change. She continued to attribute her substance use problems to other people or events. The patient was elevated risk for relapse or continued use as prior attempts to abstain from alcohol have been unsuccessful as indicated by her recent relapse. The patients recovery environment was too chaotic to support the patients treatment goals. The records document that her sisters recent death was alcohol related and she had few sober non-family supports. The patient required RTC level of care services during the period under dispute. With the resolution of her withdrawal, there was an opportunity to shift the patient to a less intensive level of care. However, but the patients sister died from complications of alcohol usage during her treatment stay. Given her history of relapse in response to stressors and level of psychiatric symptoms after her sisters death, the patient continued to require 24-hour support and RTC services for treatment of her alcohol and benzodiazepine use disorder. Thus, the patient qualified for ASAM Level 3.5 treatment similar to what she received at the RTC facility. All told, the RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 with expertise 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.