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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care. Findings:  The physician reviewer found that this patient met Level 3.1 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 for withdrawal earlier in the RTC stay. The patients withdrawal needs can safely be met in a level 3.1 setting. For dimension 2, the patient does not have any medical conditions. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring.For dimension 3, the patient is diagnosed with generalized anxiety disorder and mood disorder. He was initially transferred to a psychiatric facility for suicidal ideation with plan and continued with fluctuating degrees of passive suicidal ideation while at the RTC. He has legal problems secondary to his alcohol usage due to driving under the influence. The patient participated in groups and his mood improved during the course of his stay. The patients mental status was stable enough to permit participation, and his depression may be related to substance use problems with imminent likelihood of relapse with dangerous consequences outside of a structured environment.For dimension 4, the patient reported feeling overwhelmed and depressed with his ongoing substance use. He acknowledged the negative consequences of his substance use including legal problems, unemployment, and homelessness. The patient reported relationship discords due to poor relationships with his family and a strained relationship with mother of his children. The patient acknowledges the existence of a substance use problem, recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change, and is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been using alcohol regularly since age 12. The patient had difficulty staying motivated in his recovery. The patient is at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment.For dimension 6, the patient is homeless and unemployed. He has legal consequences from his alcohol use and does not have a sober support system outside of the facility. The patient's social network is characterized by significant social isolation and withdrawal such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care.Given these findings, the patient met the six ASAM criteria for RTC level of care. 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 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.