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) (ASAM Level 3.5) services. Findings:  The physician reviewer found that 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 1, the patient was treated for alcohol withdrawal during his hospital admission prior to the RTC treatment course. The patient reported withdrawal symptoms, which were addressed earlier in his treatment stay. The patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient did not have any documented medical problems. The patients biomedical problems were stable and did not require medical or nurse monitoring. For dimension 3, the patient was being treated for depression and anxiety. The patient underwent medication adjustments. The patient complained of some ongoing anxiety and diaphoresis. The patient 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 did not meet any of the other qualifying criteria including unable to control his use of alcohol and drugs with attendant probability of imminent danger, demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, demonstrates antisocial behavior patterns, or had significant functional deficits, which were likely to respond to staff interventions. The records do not document that the patient required medical monitoring and management or 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 did not meet the requirements for this dimension. For dimension 4, the patient admitted himself for treatment voluntarily and wanted to complete a 30-day program. The provider assessed the patient to be in the action stage of change. The records do not establish that the patient had limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between his substance use, mental health, or life problems and impaired coping skills and level of functioning, demonstrated passive or active opposition to addressing the severity of his 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 evidence that patients perspective impaired his ability to make behavior changes without repeated, structured motivational interventions, that the patient expressed little to no interest in changing, or that the patient attributed his alcohol, drug or mental health problem to other persons or external events. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 5, the patient endorsed drinking a 12 pack of beer daily for four years. The patient reported blackouts and was drinking during the day. He recognized the need for treatment and continuing care. The patient was treated with medications for cravings. The documentation does not indicate that the patient lacked insight into benefits of continuing care and is therefore not committed to treatment, was unable to control use of alcohol or drugs with attendant probability of harm to self or others, experienced cravingwith the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, or was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation. The records do not indicate that despite recent active participation in treatment at a less intensive level of care, the patient continued to use alcohol or drugs, or that the patient demonstrated a lifetime history of repeated incarceration. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 6, the patient was living in an apartment with a roommate that drinks heavily, and his partner also drinks alcohol. The provider recommended a sober living facility. The patients social network included regular users of alcohol and other drugs such that recovery goals were assessed as unachievable at a less intensive level of care. (d)Given these findings, the patient does not meet ASAM Level 3.5 requirements for dimensions 3, 4, or 5. The ASAM guidelines require adult patients to meet all six dimensions to support an indication for RTC services. Moreover, the RTC services were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the RTC (ASAM Level 3.5) services 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.