Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 30-year-old male who was admitted to a residential treatment center (RTC) on 
3/9/22. The patient has requested reimbursement for RTC services (ASAM 3.5) from 3/23/22 
through 3/29/22. The physician reviewer found that at issue is whether RTC services (ASAM 3.5) 
from 3/23/22 through 3/29/22 were medically necessary for the treatment of this patient. Per 
American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 
criteria for RTC services from 3/23/22 through 3/29/22. 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 opioid withdrawal earlier in the course 
of his treatment. The patients withdrawal needs were safely managed in a Level 3.5 setting. For 
dimension 2, the patient had a history of hypertension. The patients biomedical problems were 
stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had 
depression and anxiety. He was not suicidal or homicidal, or have a history of suicide attempts or 
aggressive behaviors toward others. He participated in group sessions. The patients mental 
status was stable enough to permit participation, but the records did not indicate that he was 
unable to control his use of alcohol or was in imminent danger of relapse, with attendant 
likelihood of harm to self, others, or property, demonstrated antisocial behavior patterns, had 
significant  functional  deficits  of  a  pervasive  nature  requiring  treatment  that  is  primarily 
habilitative in focus that were 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 at his friends recommendation. He was 
able to admit that he had an opioid use disorder and participated in his treatment. He expressed 
interest in changing due to negative effects on his relationships. The records did not indicate that 
the patient had limited insight and little awareness of the need for continuing care, marked 
difficulty  in  understanding  the  relationship  between  substance  use,  mental  health,  or  life 
problems and her impaired coping skills and level of functioning, demonstrated passive or active 
opposition to addressing the severity of her addiction problem, or required structured therapy 
and a 24 hour programmatic milieu because motivational interventions had not succeeded at 
less intensive levels of care. The patient did not have a perspective that impaired 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. This criterion was not met. For dimension 5, the patient reported 
using  one  gram  of  heroin  intravenously  daily  relapsing  in  August  of  2021  after  stopping 
methadone. He recognized the need for treatment and continuing care. The patient did not have 
a history of suicidal or homicidal ideation, suicide attempts or aggression. The records did not 
indicate that the patient lacked insight into benefits of continuing care and was therefore not 
committed to treatment, was unable to control use of alcohol or 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,  was  in  imminent  danger  of  relapse  with  dangerous 
emotional, behavioral, or cognitive consequences as a result of a crisis situation, continued to  use alcohol despite recent active participation in treatment at a less intensive level of care, or 
demonstrated a lifetime history of repeated incarceration. This criterion was not met. For 
dimension 6, the patient had relocated to the area for treatment at this facility and desired to go 
to an SLE in the area as he knew that he would relapse if he returned to his old environment. The 
records did not indicate that the patient was living in an environment characterized by a 
moderately high risk of neglect or of endemic substance abuse, or that the patient was unable to 
cope for even limited periods of time, outside of 24-hour care. The patient did not have a social 
network including regular users or dealer of substances, or have a social network characterized 
by  significant  social  isolation  and  withdrawal,  such  that  recovery  goals  are  assessed  as 
inconsistently unachievable at a less intensive level of care. This criterion was not met. Given 
these findings, the patient did not meet the six ASAM criteria for RTC services provided from 
3/23/22 through 3/29/22. Accordingly, RTC services (ASAM 3.5) from 3/23/22 through 3/29/22 
were not medically necessary for treatment of this patient.