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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dual diagnosis residential substance misuse treatment.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.1 criteria for residential treatment center services provided during the first 25 days of the services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient had been sober from alcohol for 75 days, and he did not have a significant Prediction of Alcohol Withdrawal Severity Scale (PAWSS) score. The patients withdrawal needs could be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient had a history of cerebrovascular accidents with left sided weakness, hypertension and gastritis. The patients biomedical problems, if any, were stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient was diagnosed with major depressive disorder and was suicidal upon admission. He experienced frequent suicidal ideation that was exacerbated by drinking. He had two prior attempts and was admitted for suicidal ideation on three days prior to his admission at the residential treatment center. He initially endorsed multiple symptoms of depression including hopelessness, worthlessness, anhedonia, depressed mood, poor sleep and appetite. The patients mental status permitted participation. His psychiatric condition was stable and his anxiety and depression could be related to substance use problems or to a stable co-occurring emotional condition with imminent likelihood of relapse with dangerous consequences outside of a structured environment. The patient was also assessed as not posing a risk to self or others.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily and participated actively in treatment. He recognized the effects of alcohol on his health and relationships. The patient acknowledged the existence of a substance use problem, and he 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 - Relapse, Continued use, or Continued Problem Potential. The patient had been drinking heavily for 30 years and most recently relapsed after he had three strokes. He made significant progress in addressing his relapse triggers, and he was actively working on transitioning to the community with the assistance of his daughter. He was not able to return to the camper that he was residing in due to his disability from the cerebrovascular accidents. The patient needed staff support to maintain engagement in his recovery program while transitioning to life in the community.For dimension 6 - Recovery Environment. The patient had been technically homeless, as he was living alone in a camper and going from campsite to campsite. He was socially isolated and had been experiencing frequent bouts of suicidal ideation with severe depression. He had been unable to cope with his physical disabilities after having three strokes. He is not able to reside alone due to disabilities from his strokes. The patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities. Continued exposure to his living environment, however, made recovery unlikely, and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Using the ASAM level 3.1 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.1 treatment during the first 25 days of the services at issue. Accordingly, the dual diagnosis residential substance misuse treatment provided during the first 25 days of the services at issue was medically necessary to treat the patients condition.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient did not meet Level 3.1 criteria for residential treatment center services provided during the next 29 days of the services at issue. Regarding dimension 5 - Relapse, Continued use, or Continued Problem Potential  during this period, the patient was noted to be able to identify triggers and coping skills. He was described as engaged, positive, focused and motivated, and he was described as having taken on a leadership role. His depressed mood had stabilized, and he no longer needed staff support to maintain engagement in his recovery program. Given these status changes, the patient no longer met the dimension 5 criteria for Level 3.1. Regarding dimension 6 - Recovery Environment - the patient was noted to have changed his mind regarding his original discharge plan, as he reconciled with his significant other and intends to move in with her rather than his daughter, which had been the patients earlier discharge plan. Given these status changes, the patient no longer met the dimension 6 criteria for Level 3.1. Accordingly, the dual diagnosis residential substance misuse treatment provided during the next 29 days of the services at issue was not medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were partially medically necessary to treat the patient's condition. Therefore, the Health Plans denial should be partially 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.