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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) (ASAM Level 3.5) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet the ASAM criteria for RTC services (ASAM Level 3.5). 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 treated with benzodiazepines for withdrawal management earlier in his treatment stay. The patients withdrawal needs could have been safely managed in Level 3.5 setting. For dimension 2, the patient has gastroesophageal reflux disease (GERD). The patients biomedical problems, if any, were stable and did not require medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with generalized anxiety disorder and major depressive disorder. He was not suicidal, homicidal, and he was able to perform activities of daily living. The provider charted that the patient participated in groups. The patients mental status was 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 co-occurring psychiatric conditions were being addressed concurrently through appropriate psychiatric services. For dimension 4, the patient admitted himself for treatment of his alcohol use disorder as he was experiencing many negative consequences from his alcohol usage. The patient expressed a desire to become abstinent and he was able to identify negative consequences of alcohol usage, including occupational problems and relationship problems. The patient required structured therapy and 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care and such interventions were assessed as not likely to success at a less intensive level of care.  For dimension 5, the patient endorsed drinking a fifth of vodka on a daily basis for the past five years. The patient demonstrated insight into his relapse triggers. The patient did not meet any of the criteria for this dimension, including imminent danger of relapse, understands addiction and mental disorder but was at risk of relapse in a less structured level of care, or needed staff support to maintain engagement in his recovery program while transitioning to life in the community. Based on these findings, the patient did not meet the requirements for this dimension. For dimension 6, the patient lived with his parents and has a supportive girlfriend. There was no abuse or substance usage in the home environment. His parents were supportive of his sobriety. The patient did not meet the criteria for this dimension, including living in an environment that is characterized by repetition of physical or emotional abuse, a social network characterized by significant social isolation and withdrawal, a living environment highly invested in alcohol, or unable to cope, even for limited periods of time, outside of 24-hour care. Based on these findings, the patient did not meet the requirements for this dimension.The ASAM framework requires adult patients to meet all six dimensions to meet the requirements for RTC services. This patient did not meet dimensions 5 or 6. Moreover, the RTC services were not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration for treatment of this patient. Therefore, the RTC services (ASAM Level 3.5) 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 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.