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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all, or any, residential treatment center (RTC) ASAM Level 3.5 services.  Findings:  The physician reviewer found that 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 was managed with a Valium taper earlier in his RTC stay. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient has a diagnosis of HIV. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported symptoms of depression and anxiety, paranoia after methamphetamine use, and being the victim of a recent assault. The patient participated in group sessions. The patient was not suicidal or homicidal, and there were no noted functional deficits. The patients mental status was stable enough to permit participation, but the records did not document an inability to control alcohol and drug use with imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrated patterns of antisocial behavior, significant functional deficits of a pervasive nature requiring treatment that was primarily habilitative in focus and likely to respond to staff interventions, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provided opportunities to promote continuous boundary setting interventions. This criterion was not met.For dimension 4, the patient admitted himself for treatment voluntarily following a weekend with alcohol and drug use and being the victim of an assault. The patient participated in his treatment. The records did not note limited insight and little awareness of the need for continuing care, a marked difficulty in understanding the relationship between his substance use, mental health, or life problems and his impaired coping skills and level of functioning, passive or active opposition to addressing the severity of his addiction problem, or a perspective impairing his ability to make behavior changes without repeated, structured motivational interventions. The patient did not require structured therapy and a 24 hour programmatic milieu because motivational interventions had not succeeded at less intensive levels of care, express little to no interest in changing, or attribute his alcohol, drug or mental health problem to other persons or external events.  This criterion was not met.For dimension 5, the patient reported drinking up to ten drinks daily, starting in the morning, for the past two months. He had recently been the victim of assault during gamma hydroxybutyrate (GHB) use. The records did not note suicidal or homicidal ideation, attempted suicide, aggression, or issues of probability of harm to self or others. The patient did not lack insight into the benefits of continuing care, did not have an inability to control use of alcohol or drugs with attendant probability of harm to self or others, and was not experiencing cravings with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. He was not in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, continuing to use despite recent active participation in treatment at a less intensive level of care, or demonstrating a lifetime history of repeated incarceration. This criterion was not met. For dimension 6, the patient lived alone in an isolated area. The patients social network was characterized by significant social isolation and withdrawal such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient did not meet the six ASAM criteria for RTC services. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the RTC ASAM Level 3.5 services from 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 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.