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 (ASAM Level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for RTC services (ASAM level 3.5). 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 alcohol withdrawal earlier in his course of treatment. The patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient was reported to have tremors and gait disturbance. The records support that the patients 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 has been diagnosed with major depressive disorder and generalized anxiety disorder. The records indicate that the patient was not suicidal or homicidal, and he does not have a history of overdose, suicide attempts, or aggressive behaviors toward others. The provider noted that the patient participated in individual and group therapies. Overall, the records document that the patients mental status was assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. However, there is a lack of support that the patient was unable to control his use of alcohol and drugs with attendant probability of imminent danger, demonstrated repeated inability to control his impulses to use alcohol and other drugs and was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The records do not document that the patient demonstrated antisocial behavior patterns, had significant functional deficits, which were likely to respond to staff interventions...of pervasive nature requiring treatment that was primarily habilitative in focus,  or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 4, the patient admitted himself for treatment voluntarily after falling while intoxicated. The patient was able to admit that he has an alcohol use disorder and he participated in his treatment. The patient expressed interest in changing due to negative effects on his health and his marriage. Thus, there is a lack of documentation to support that the patient required 24-hour programmatic milieu to sustain motivation. The patient did not demonstrate limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between his substance use, mental health, or life problems and his impaired coping skills and level of functioning, or demonstrate passive or active opposition to addressing the severity of his addiction problem. The records do not indicate that the patient required structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care, or that the patients perspective impaired his ability to make behavior changes without repeated, structured motivational interventions, or that the patient attributed his alcohol, drug or mental health problem to other persons or external events. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 5, the patient was drinking 1.5 pints of liquor daily since he relapsed five months prior to admission. He recognized the need for treatment and continuing care. He has no suicidal ideation or homicidal ideation. He has never attempted suicide and has not been noted to be a danger to others. The records do not establish that the patient lacked insight into benefits of continuing care, that he experienced craving...with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, or that the patient was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation. The records do not demonstrate that despite recent active participation in treatment at a less intensive level of care, the patient continued to use alcohol or drugs, or that the patient demonstrated a lifetime history of repeated incarceration. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 6, the patient was previously living with his wife, who drinks in the house. There was a family meeting to discuss his wifes drinking, but the wife did not show on one occasion. There is documentation that the patients social network involved living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs. The ASAM guidelines require that adult patients meet all six dimensions to support an indication for RTC services. Based on the records provided for review, this patient does not meet Level 3.5 RTC criteria for dimension 3, 4, or 5. Therefore, the RTC services (ASAM level 3.5) 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.