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 substance-related disorders, residential behavioral health level of care, adult rehabilitation treatment. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 patients withdrawal needs can be met in a Level 3.1 setting. The patient has symptoms of anxiety, irritability, and agitation. He has completed a benzodiazepine taper but continues to have elevated CIWA scores. For dimension 2, the patient has hypertension and complaints of edema. The patients biomedical problems are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patients mental status is stable to permit participation. The patients symptoms and functional limitations, when considered in the context of his home environment, are sufficiently severe that he is assessed as not likely to maintain abstinence if treatment is provided in a nonresidential setting. The patient was diagnosed with major depressive disorder. He reported significant anxiety about returning home due to stressors and conflicts. He has been managing his anxiety and mood by drinking alcohol. He feels that his family is not supportive of him. He was actively participating in groups. For dimension 4, the patient acknowledges the existence of a substance use problem. He is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. The patient voluntarily admitted himself due to the severity of his alcohol us. The patient reported that he was drinking all day and he has been unable to stop drinking on his own. The provider noted that the patient has demonstrated motivation to complete the program. For dimension 5, the patient understands his addiction and mental disorder but is at risk of relapse in a less structured level of care because he is unable to consistently address either or both. The patient has a severe alcohol use disorder with a high daily consumption of alcohol. He went through alcohol withdrawal and had significant withdrawal symptoms for an extended time. He has relapsed twice since his last RTC stay in September 2019. He uses alcohol in a maladaptive manner in order to cope with the stressors in his life. For dimension 6, the patient has been able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment makes recovery unlikely and the patient has insufficient resources and skills to maintain adequate level of functioning outside of a 24-hour supportive environment. The patient lives with his wife and two young children. He is struggling with his sexuality and he feels unsupported by his family. The provider noted that the patient has been anxious about his return home due to these conflicts. Given these findings, the patient meets the six ASAM dimensions for RTC services. Thus, the substance-related disorders, residential behavioral health level of care, adult rehabilitation treatment was and is medically necessary for the 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 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.