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) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet 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 alcohol withdrawal with a valium taper. Based on clinical findings, the patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient does not have significant 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 is noted as being diagnosed with depression and anxiety. The patient reported using alcohol to manage her anxiety. While at the RTC, the patient was restarted on Effexor. The patient was not suicidal or homicidal, and she does not have history of overdose, suicide attempts, or aggressive behaviors toward others. She participated in groups. 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. However, the patient does not meet any of the other qualifying criteria including unable to control her use of alcohol and drugs with attendant probability of imminent danger, demonstrated repeated inability to control her impulses to use alcohol and other drugs and was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrated antisocial behavior patterns, or has significant functional deficits, which are likely to respond to staff interventions. The records do not support that the patient had concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provided opportunities to promote continuous boundary setting interventions. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 4, the patient voluntarily admitted herself for treatment. The patient was able to admit that she has alcohol use disorder and she participated in her treatment. The patient expressed interest in changing, but she was reluctant to participate in intensive outpatient program (IOP) or Alcoholics Anonymous (AA) as recommended. There is a lack of documentation that the patient demonstrated limited insight and little awareness of addiction problems, demonstrated passive or active opposition to addressing the severity of her addiction problem, or required structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care. There is a lack of support that the patients perspective impaired her ability to make behavior changes without repeated, structured motivational interventions, that she expressed little to no interest in changing, or that the patient attributed her alcohol problem to other persons or external events. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 5, the patient endorsed drinking three bottles of wine daily for the year prior to admission. She presented voluntarily for treatment, and she has prior history of successful treatment with five years of sobriety until she started to drink in 2019. She denied cravings for alcohol as of mid-October 2021. She recognized the need for treatment of her alcohol use disorder but was unsure about resuming AA and did not want to participate in IOP. The patient does not have a history of suicidal ideation or homicidal ideation. She has never attempted suicide and has not been noted to be a danger to others. The records do not document that the patient lacked insight into benefits of continuing care and was therefore not committed to treatment, unable to control use of alcohol or drugs with attendant probability of harm to self or others, or experienced craving...with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. There is a lack of support that the patient was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, or despite recent active participation in treatment at a less intensive level of care, the patient continues to use alcohol or drugs, or demonstrates a lifetime history of repeated incarceration. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 6, the patient was living alone in an apartment, but she was spending time with friends who drink alcohol on a regular basis. The patients family was supportive of her recovery and recommended that she consider other living arrangements. The records support that the patients social network included regular users of alcohol such that recovery goals were assessed as unachievable at a less intensive level of care. The ASAM criteria require adult patients to meet all six dimensions to support Level 3.5 RTC services. This patient does not meet Level 3.5 RTC criteria for dimensions 3, 4, or 5. 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 these reasons, the RTC services for substance use disorder (ASAM 3.5) provided at AToN Center 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.