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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 2, the patient had hypertension, which though elevated, did not meet the criteria for hypertensive urgency, and chronic constipation. 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 and depression. The patients mental status permitted participation. The patient had a demonstrated repeated inability to control his impulses to use substances and continued to have high levels of cravings, anxiety, and poor sleep. The resulting level of dysfunction precluded participation in a less structured and intensive level of care.For dimension 4, the patient recognized that his substance abuse escalated significantly during the past holiday season, causing psychosocial discord. The patient did not possess adequate coping skills to stay sober, and required the structured therapy and 24-hour programmatic milieu to promote treatment progress and recovery, as lower levels of care would not have been successful. For dimension 5, the patient reportedly remained sober for five months following detoxification and outpatient program two years ago. He relapsed on alcohol and methamphetamine over the past holiday season. He was experiencing psychiatric and addiction symptoms, such as intense drug cravings. Nursing notes for the dates of service at issue documented symptoms, including elevated and increased cravings, anxiety, poor sleep, auditory hallucinations, elevated blood pressure, and feelings of irritability, fear, dread, poor focus, poor memory and restlessness. The records noted nightmares and flashbacks. The patients polysubstance use predisposed him to a higher risk of protracted withdrawal symptoms. The patient had limited ability to interrupt the relapse process or continued use and posed an imminent danger to self or others in the absence of 24-hour monitoring and structured support.For dimension 6, the patient lived with his husband and mother-in-law, who both had alcohol in the home. The home environment was described as strained and stressful due to caring for his mother-in-law, who had Alzheimers, and due to the patients alcohol abuse. The patients social network included regular users of alcohol such that recovery goals were assessed as unachievable at a less intensive level of care.Given these findings, the patient met the six ASAM dimensions for RTC services at issue. Therefore, the RTC services at issue were medically necessary for the 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 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.