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 3.1 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 was admitted to the RTC and underwent withdrawal management for alcohol withdrawal. The patients withdrawal needs can be met in Level 3.1 setting. For dimension 2, the patient has underlying medical conditions of type 2 diabetes, hypertension, and hypertension. He also had a symptomatic COVID-19 infection while in the RTC and was quarantined during this period. The patients biomedical problems were stable and did not require medical or nurse monitoring. For dimension 3, the patient endorsed drinking a fifth of vodka daily for the past five years with only a six month period of sobriety. He was unable to maintain sobriety in his home environment or sober living facility prior to admission. He was drinking to manage post-traumatic stress disorder (PTSD) symptoms and anger. The provider reported that the patient participated in groups. The patients mental status was assessed as sufficiently stable to permit participation in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients symptoms and functional limitations, when considered in the context of his home environment, were sufficiently severe that he was assessed as not likely to maintain abstinence if treatment was provided in a nonresidential setting. Functional limitations included residual psychiatric symptoms, chronic addictive disorder, and the sequelae of trauma. For dimension 4, the patient voluntarily admitted himself after he was removed from his sober living facility for drinking and using cocaine. Prior treatment has included three shorter admissions to RTC facilities over the past year. He was able to identify specific negative consequences of his alcohol usage, including relationship problems. The patient acknowledged the existence of substance use problem. He recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient was drinking a fifth of vodka daily for the last five years and he has been drinking regularly since age 13. He has been trying to quit for the past year by going to shorter stay programs, but he has been unable to achieve significant sobriety due to inability to control impulses to drink. He has ongoing anger difficulties and PTSD symptoms that he manages with alcohol. He has history of aggressive outbursts when drinking and he has experienced multiple legal issues related to his alcohol use. The patient demonstrated limited coping skills to address relapse triggers and urges. He was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient has been homeless after being evicted from a sober living facility after he relapsed on alcohol and cocaine while staying there. He was then living on the streets until his sister found him to take him to treatment. He is going through a divorce and has two children. He has a limited sober support system that consists of his sister. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment made recovery unlikely, and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the 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.