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. 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 underwent withdrawal management on the detoxification unit prior to his transfer to the residential unit. Based on clinical findings, the patients withdrawal needs could have been met in Level 3.5 setting. For dimension 2, the patient has hypertension, transaminitis, and seizure disorder. 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 reported depressive and anxiety symptoms. He struggled with feelings of guilt, worthlessness, and anxiety. He was not suicidal or homicidal. There were no noted functional deficits. He 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 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, has significant functional deficits, which are likely to respond to staff interventions, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide 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 voluntarily admitted himself for treatment due to the effects his alcohol use was having on his relationships and occupational performance. The provider charted that the patient participated in his treatment. The patient did not have limited insight and little awareness of the need for continuing care, demonstrate passive or active opposition to addressing the severity of his addiction problem, have impaired perspective in his ability to make behavior changes without repeated, structured motivational interventions, express little to no interest in changing, or attribute 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 10-12 beers daily for the past five years except for an eight-month period of sobriety when he was in an RTC. He demonstrated good insight into his alcohol use disorder and need for treatment. He was treated for urges to use alcohol with Campral. He denied suicidal ideation and homicidal ideation. The patient did not lack insight into benefits of continuing care. He was not unable to control use of alcohol or drugs with attendant probability of harm to self or others, and he was not in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation. The records do not support that despite recent active participation in treatment at a less intensive level of care, the patient continued to use alcohol or drugs or 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 lives with his fiance in a sober household. The patient is employed, and his family is supportive. The patient did not meet criteria of living in an environment characterized by a moderately high risk of neglect, have a social network including regular users of drugs such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care, or unable to cope, for even limited periods of time outside of 24-hour care. Based on these findings, the patient did not meet the requirements for this dimension. Given these findings, the patient did not meet Level 3.5 RTC criteria for dimensions 3, 4, 5, and 6. Therefore, the RTC 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.