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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the RTC services provided at Sonoma Recovery Services. Per American Society of Addiction Medicine (ASAM) criteria, 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 noted to have withdrawal symptoms of insomnia, anxiety, and intense cravings. Her withdrawal was managed with a five-day diazepam taper. The patients withdrawal needs were safely managed in level 3.1 setting. For dimension 2, the patient does not have any medical problems. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with generalized anxiety disorder. She had a significant history of alcohol abuse. The patients mental status was stable enough to permit participation, her anxiety may have been related to substance use problems she was not assessed as not posing a risk to self or others. For dimension 4, the patient admitted herself for treatment at the encouragement of her employer. She reported drinking 750 mL of vodka daily and while on the job. She expressed a desire to become abstinent and was able to identify negative consequences of her alcohol usage including health problems, occupational problems, and relationship problems. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care. For dimension 5, the patient has been drinking 750 mL of vodka daily. She reported a history of heavy drinking since age 19 with a three to four month period of sobriety. She had two withdrawal seizures when attempting to quit on her own. She reported difficult family interactions, and that her parents both drank and were relapse triggers. The patient demonstrated limited coping skills to address relapse triggers and urges, was in imminent danger of relapse with dangerous consequences, and needed 24-hour structure to help her apply recovery and coping skills.For dimension 6, the patient lived alone and was socially isolated. She reported that her parents endorsed drinking. Her employment was at risk due to drinking daily in the mornings and attending work inebriated. 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, and continued exposure to the patients work or living environment made recovery unlikely. The patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, all RTC services provided at Sonoma Recovery 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 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.