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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any or all of the residential treatment center (RTC) services provided by Mountain Vista Farm. Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.1 nor Level 3.5 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 managed for withdrawal on a diazepam taper. The patients withdrawal needs were safely managed in a level 3.1 setting. For dimension 2, the patient had hypertension and was status post hip replacement. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had symptoms of depression and anxiety. He was not suicidal or homicidal. He was attending group therapies. The patients mental status was stable enough to permit participation. He was not in imminent likelihood of relapse with dangerous consequences outside of a structured environment and did not endorse symptoms and functional limitations that were sufficiently severe that he was unlikely to maintain mental stability and abstinence in a nonresidential setting. This criterion was not met. For dimension 4, the patient admitted himself for treatment for alcohol use disorder at the urging of his wife. He expressed his desire to become abstinent and was able to identify negative consequences of alcohol use including occupational problems and relationship problems. The patient recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient was drinking a fifth of vodka daily for the past year. He reported 18 months of sobriety on his own three years prior. This was his first attempt at treatment. The patient had insight into relapse triggers and was actively working on developing coping skills. He was not in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences, at risk of relapse in a less structured level of care due to an inability to consistently address both his addiction and mental disorder, or in need of close 24-hour monitoring and structured treatment while transitioning to life in the community. This criterion was not met.For dimension 6, the patient lived with his wife who supported his sobriety. He was unemployed due to his drinking. He has previously contacted Alcoholics Anonymous in his community. The patient was not living in an environment characterized by a repetition of physical or emotional abuse, lacking in social contacts and social network, in a living environment highly invested in alcohol, or without sufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. This criterion was not met.Given these findings, the patient did not meet the six ASAM criteria for RTC services. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, RTC services provided by Mountain Vista Farm 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 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.