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 1, the patient underwent prior withdrawal management for alcohol use disorder. The patients withdrawal needs could have been safely managed in Level 3.5 setting. For dimension 2, the patient is status post hip replacement and needs his other hip to be replaced. The patient complained of ongoing pain. The patients biomedical problems, if any, were stable and did not require medical or nurse monitoring and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has a history of several involuntary psychiatric hospitalizations for a psychotic disorder with the most recent admission only one month prior to the current admission. He has required psychiatric admissions for suicidal threats and threats to harm his brother. He was noted to be impulsive and grandiose while in treatment. He did participate 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. The patient demonstrated repeated inability to control his impulses to use alcohol and to engage in antisocial behavior 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, the patient was admitted voluntarily due to being unable to control his drinking, which he stated was to manage his pain from hip arthritis. The patient denied that alcohol was a problem for him and that he would be able to drink in moderation in the future. He also made comments about having the cure for addiction. The patients perspective impaired his ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which would have enabled him to develop insight into the role he plays in his substance use and mental condition and empower him to make behavioral changes which could only be delivered in a 24-hour milieu. For dimension 5, the patient admitted himself voluntarily due to his family being concerned about his level of drinking. He rationalized that he was drinking heavily to manage his hip pain. The patient endorsed drinking 75 mL of vodka daily since he relapsed. He stated that he felt he would be able to drink socially, and he denied that he had a problem with alcohol. This patient was previously involuntarily psychiatrically hospitalized for delusions and threats to kill himself. He has a prior history of involuntary hospitalizations for threats to harm his brother. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment. His continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient reported that he was living with his mother and brother but that he cannot return there since they were not treating him well. The patient indicated that he was going through his third divorce and he does not live with his children. He is not employed. The records suggest that the patient does not have an outside support system. The patient was living in an environment that is characterized by a moderately high risk of repetition of emotional abuse that the patient was assessed as being unable to achieve or maintain recovery at a less intensive level of care. Given these findings, the patient met the six ASAM dimensions for RTC services. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the substance abuse 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.