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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that (ASAM) criteria, this patient does not meet Level 3.1 or Level 3.5 criteria for rehabilitation 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 admitted to RTC and he declined withdrawal management with diazepam. The patients withdrawal needs can be safely managed in Level 3.1 setting. For dimension 2, the patient has gastroesophageal reflux disease (GERD) and fatty liver disease. The patients biomedical problems, if any, are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has diagnoses of depression, anxiety, and post-traumatic stress disorder (PTSD). The patient reported that over the past year, he has lost his job and several family members. He also lost his home and most of his belongings in a fire. The patients mental status has been assessed as sufficiently stable to allow 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 criteria listed including imminent likelihood of relapse with dangerous consequences outside of a structured environment, sufficiently severe symptoms and functional limitations such that he is assessed as not likely to maintain mental stability and abstinence if treatment is provided in a nonresidential setting, demonstrates an inability to maintain stable behavior over a 24-hour period without the structure and support of a 24-hour setting, or co-occurring psychiatric, emotional, behavioral, or cognitive conditions are being addressed concurrently through appropriate psychiatric services. Based on these findings, the patient does not meet the requirements for this ASAM dimension.For dimension 4, the patient admitted himself for treatment of his alcohol use disorder since he was unable to stop drinking on his own. He has expressed a desire to become abstinent and he is able to identify negative consequences of alcohol usage including social, relationship, and occupational problems. The patient acknowledges the existence of a substance use problem and he recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has reportedly been using alcohol in a binge type pattern of drinking two bottles of wine daily for periods of time followed by up to two months of sobriety. He has experienced an increase in his drinking since losing his home and most of his belongings in a fire. This is his first attempt at RTC level of care services. He was started on Campral for cravings. He has been developing insight into relapse triggers and actively working on developing coping skills. The patient does not meet the criteria for this dimension including imminent danger of relapse, understands addiction and mental disorder but is at risk of relapse in a less structured level of care, or needing staff support to maintain engagement in his recovery program while transitioning to life in the community. Based on these findings, the patient does not meet the requirements for this ASAM dimension.For dimension 6, the patient lives with his parents in a sober and supportive household. His father is in recovery. He lost his job and is unemployed. He is attending college online. The patient is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities but does not meet any of the other criteria for this dimension including living in an environment that is characterized by repetition of physical or emotional abuse, lacks social contacts and social network is characterized by significant social isolation and withdrawal, living environment highly invested in alcohol, has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment, or in danger of victimization. Based on these findings, the patient does not meet the requirements for this ASAM dimension. ASAM requires adult patients to meet all six dimensions to support treatment at the RTC level of care. This patient does not meet criteria for dimensions 3, 5, and 6. Moreover, the RTC services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the RTC level of care services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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.