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 any or all of the requested residential treatment center (RTC) services provided by The Lakes Treatment Center.At issue is whether any or all of the residential treatment center (RTC) services provided by The Lakes Treatment Center were medically necessary for the treatment of this patient.For dimension 1, the patient was noted to have withdrawal symptoms of agitation, tremors, and anxiety. He completed a Librium taper. The patients withdrawal needs were safely managed in level 3.5 setting. For dimension 2, the patient was status post motor vehicle accident while driving under the influence of alcohol. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had a history of anxiety, depression, and social anxiety. For dimension 4, this treatment was prompted following an occurrence of driving under the influence of alcohol resulted in a motor vehicle accident. He had legal issues due to driving under the influence of alcohol. He blamed his alcohol and Xanax usage on others. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care. For dimension 5, patient had multiple relapses despite attempting to stay sober and a history of five prior treatment attempts. He was noted to have limited insight into reasons for relapse, blaming his alcohol usage for dysfunctional relationships, anxiety, and difficulty in managing conflict. He had a history of accidental overdoses due to combining alcohol and benzodiazepines. Most recently, he was involved in a motor vehicle accident while driving under the influence. Despite his best efforts, the patient is unable to control his use of alcohol and other drugs with attendant probability of harm to self or others. The patient has limited ability to interrupt the relapse process or to use peer supports when at risk for relapse to his addiction. The patient continued to use alcohol and substances with imminent serious consequences and was at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient was living with his girlfriends parents, which he described a stressful and dysfunctional. The patient did not have a sober support system such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, the RTC services provided at The Lakes Treatment Center were medically necessary for treatment of this patientAt issue is whether any or all of the requested residential treatment center (RTC) services provided by The Lakes Treatment Center were and are medically necessary for the treatment of this patient.Per American Society of Addiction Medicine (ASAM) criteria, this patient met 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 had previously undergone withdrawal management for alcohol and continued to experience moderate withdrawal symptoms including agitation, anxiety, headaches, tremors, and visual disturbance. The patients withdrawal needs can be safely managed in level 3.1 setting. For dimension 2, the patient had a symptomatic COVID 19 infection while in treatment and was quarantined. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was transferred back to the RTC following admission to a higher level of care and hospitalization due to suicidal ideation with plan. He was described as isolative, withdrawn, and depressed. He had been unable to maintain sobriety in his home environment and had been drinking to manage anxiety and depression symptoms. The patients mental status was stable enough to permit participation, and his symptoms and functional limitations, when considered in the context of his home environment, are sufficiently severe that he is in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient voluntarily readmitted himself to RTC following his psychiatric admission for suicidal ideation with plan, and had a history of RTC stays. He was able to identify specific negative consequences of his alcohol usage including legal, occupational, and relationship problems. The patient is sufficiently ready to change and cooperative enough to respond to treatment at level 3.1.For dimension 5, the patient has been drinking a fifth of vodka or 18 to 24 beers daily for the past one to two years. He had a history of RTC treatment attempts and relapses.  He has ongoing anxiety and depressive symptoms that he managed with alcohol use, and a history of unintentional overdoses on alcohol and Xanax. He had a prior occurrence of driving under the influence. The patient demonstrates limited coping skills to address relapse triggers and urges, and is in imminent danger of relapse with serious consequences in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient has decided to leave his housing situation and is currently without income or vehicle, and is unemployed. He does not have a sober support system outside of professional staff and the 12-step environment. Continued exposure to the patient's living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Given these findings, the patient meets the six ASAM criteria for RTC services. Accordingly, the RTC services provided at The Lakes Treatment Center were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services were and are 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 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.