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 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 patient was monitored and treated for alcohol withdrawal with a Librium protocol. The patients withdrawal needs can be met in Level 3.1 setting.For dimension 2, the patient does not have any active medical problems. 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 patient was diagnosed with generalized anxiety disorder while in the RTC and started on BuSpar. He admits to using alcohol as a way of coping with his anxiety. The provider noted that the patient participated in groups. The patients mental status is assessed as to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition is stable and he is assessed as having minimal problems in this area as evidenced by anxiety that may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment and the patient is assessed as not posing a risk of harm to self or others. For dimension 4, the patient admitted himself to RTC with the help of his parents voluntarily after recognizing that he was unable to stop drinking on his own. He has been in the contemplative stage of change and is able to identify negative consequences of his alcohol usage such as job loss, relationship problems, and legal issues. The patient acknowledges the existence of a psychiatric condition and substance use problem. He recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been drinking a handle of vodka for the past four years. He has a 57-day period of sobriety and no prior attempts at treatment. He demonstrated poor insight into triggers of his alcohol usage. The patient alcohol demonstrates limited coping skills to address relapse triggers and urges. He is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient recently lost his job due to his alcohol use disorder. He indicated that all his friends are drinkers and he is otherwise socially isolated. He will be returning home to live with his brother after his discharge from the RTC. The patient is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. The patient has high-risk social contacts that jeopardize his recovery, and his sober social network is characterized by significant social isolation and withdrawal. The patients social network includes many friends who are regular users of alcohol, leading recovery goals to be assessed as unachievable outside of a 24-hour supportive environment. These findings demonstrate that the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC level of care 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 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.