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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.5 criteria for the residential treatment center services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient had been drinking 14 units of alcohol daily and had previously had withdrawal seizures. Her last drink was on the day before her admission, and she underwent withdrawal management. The patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient had a history of alcohol withdrawal seizures, hypomagnesemia, and hyperlipidemia. She was noted to be medically stable during her admission.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient had ongoing anxiety and dysphoria that she had been unable to manage without drinking alcohol. She had documented repeat admissions to detoxification facilities that were followed by an immediate relapse within days that she attributed to anxiety. The patient had two reported recent alcohol withdrawal seizures. The patient met the subcriteria of having a mental status that was stable enough to permit participation. At the same time, the patient demonstrated a 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. The resulting level of dysfunction was of such severity that it precluded participation in treatment in the absence of the 24-hour support and structure of a level 3.5 program.For dimension 4 - Readiness to Change. The patient admitted herself voluntarily due to being unable to stop drinking despite ongoing attempts at a lower level of care. She had a sobriety coach and had been going to short-term detoxification treatment and relapsing once out of the facility. Despite voicing willingness to change, the patient had not been able to enact such changes at a lower level of care. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions had not succeeded at less intensive levels of care and such interventions were not likely to succeed at a less intensive level of care.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient had problematic alcohol usage of 10 years duration. Her longest period of sobriety had been 45 days. In the six weeks preceding this admission, the patient had three 3-day detoxification admissions and was working with a sobriety coach. The patient attended an intensive outpatient program, but she relapsed immediately afterwards. Therefore, despite recent active participation in treatment at a less intensive level of care, the patient continued to use alcohol, with 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 - Recovery Environment. The patient lived with her husband, who also had an alcohol use disorder. Notes indicate that the patients husband had developed cirrhosis and esophageal varicies from his alcohol usage. The patients social network therefore involved living with an individual who was an addicted user.Using the ASAM level 3.5 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.5 treatment. Accordingly, the residential treatment center services at issue were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patient's 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.