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 behavioral health residential treatment center (RTC) services. Findings:  The physician reviewer found that 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 admitted to RTC 2 6 days after she started withdrawal management with diazepam taper. The patients withdrawal needs can be safely managed in Level 3.1 setting. For dimension 2, the patient has been diagnosed with celiac disease and hypothyroidism. 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 has a history of abuse by her ex-boyfriend. She is fearful and anxious, and she reported that she was drinking an increasing amount of alcohol to manage her anxiety. The records indicate that she is participating in groups. The patients mental status is assessed as sufficiently stable 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 she is assessed as having minimal problems in this area as evidenced by anxiety 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 herself voluntarily as she recognized the effect her drinking was having on her children and her employment. She has expressed a desire to remain sober and is able to identify negative consequences of her addiction. The patient acknowledges the existence of a psychiatric condition and substance use problem. She recognizes specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been drinking five mixed drinks daily for the past year and her usage has increasing since she first started drinking at age 15. This is her first attempt at treatment. She has stressors that would be relapse triggers including lack of sober supports and fear of her ex-boyfriend. She is experiencing trouble regulating her emotional response to her fears. She reported ongoing severe cravings and was started on Acamprosate and gabapentin to help attenuate these urges to drink. The patient demonstrates limited coping skills to address relapse triggers and urges. She is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient has a history of a volatile relationship with her ex-boyfriend and she has a restraining order in place for her safety. 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 and vocational activities. The patient has been living in an environment that is characterized by a moderate risk of initiation or repetition of physical and emotional abuse such that the patient is assessed as being unable to maintain recovery at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the behavioral health RTC level of care services were and are medically necessary for 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 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.