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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for ASAM Level 3.5 residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria this patient met Level 3.5 criteria for RTC services. The 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 underwent withdrawal management for alcohol withdrawal earlier in her treatment. The records document that the patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient did not have any reported active medical problems. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient had an episode of substance-induced psychosis that was precipitated by taking large amounts of Adderall and staying up for three days at a time. The patient endorsed drinking two bottles of wine plus a fifth of liquor on a daily basis for two years. The patient drinks to the point of blackouts and she has encountered legal issues as a result of her alcohol use disorder. The patient continued to show evidence of impulse dyscontrol while in the RTC with frequent medication-seeking behaviors and compulsive tea drinking. The patient also requested treatment with Adderall while in the RTC and she reported that she would likely return to taking it after she completed her residential treatment. The patients mental status was assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. In addition, the patient has demonstrated a repeated inability to control her impulses to use alcohol and other drugs or to engage in antisocial behavior and was in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction was of such severity that it precluded participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was admitted voluntarily for treatment since her alcohol use was  adversely affecting nearly every aspect of her life and she realized that she was unable to stop at home due to withdrawal symptoms. The patient endorsed drinking since she was 13 and started having blackouts at age 15. She has been drinking two bottles of wine plus a fifth of liquor daily for the past two years. She has also been abusing Adderall and Vyvanse for the past two years to the point of having psychosis. She does not recognize the severity of her stimulant usage or the inter-relationship between her stimulant usage and her alcohol usage. She was requesting to have Adderall prescribed to her while on the unit. Because of the intensity and chronicity of the addictive disorder, she had limited insight and little awareness of the need for continuing care or the existence of her substance use and need for treatment, and thus had limited readiness to change. For dimension 5, this was the patients second attempt at treatment. The patients first attempt at treatment was an IOP followed by three months of sobriety. Since then, the patient reported that she was drinking two bottles of wine plus a fifth of liquor on a daily basis, and she was unable to decrease use or stop at home due to withdrawal symptoms. The patient has experienced blackouts, legal consequences, and substance-induced psychosis due to her alcohol and substance use disorders. The patient was unable to understand the severity of her stimulant usage or the connection between her stimulant usage and risk of relapse on alcohol. The patients behaviors were centered on medication-seeking, and she reported that she would return to Adderall after her treatment episode for alcohol use disorder was over. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment. Her continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patients roommate asked her to move out due to the severity of her alcohol and stimulant usage. The patient also lost her job and encountered legal issues due to her alcohol usage. The patients peer group consisted of drinkers and drug users. The patients social network involved regular users of alcohol and drugs such that the patients recovery goals were assessed as unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM dimensions for Level 3.5 RTC services. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, and clinically appropriate in terms of type, frequency, extent, site, and duration. All told, the ASAM Level 3.5 RTC 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 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.