Appeal type: Medical Necessity
Decision: Overturned 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. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 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 admitted to RTC after completing a seven-day detoxification at a different facility. She continued to have withdrawal symptoms of insomnia, anxiety, and intense cravings. The patients withdrawal needs can be met in Level 3.1 setting.For dimension 2, the patient is pregnant with 24-week intrauterine pregnancy. She has a history of withdrawal seizures and perforated gastric ulcer from her alcohol use disorder. The patients biomedical problems 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 significant difficulties with PTSD with symptoms of insomnia, nightmares, and depression. She has been frequently passively suicidal and anxious. She has been participating 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 patients symptoms and functional limitations, when considered in the context of her home environment, are sufficiently severe that she is assessed as not likely to maintain mental stability and abstinence if treatment is provided in a nonresidential setting. Functional limitations may include residual psychiatric symptoms, chronic addictive disorder, history of criminality, and emotional trauma. For dimension 4, the patient admitted herself for treatment after experiencing severe urges to drink after completing a seven-day detoxification. She is currently in her second trimester of pregnancy and was drinking 750 mL of vodka every two to three days. She has expressed desire to remain clean and abstinent and she has been able to identify negative consequences of her alcohol usage including teratogenic effects on the fetus. The patient acknowledges the existence of a substance use problem. She recognizes specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been drinking 750 mL of vodka every two to three days since learning of her pregnancy. She was previously drinking one pint of vodka daily for the past 15 years. Her last period of sobriety ended after she was triggered by PTSD symptoms. She admitted herself voluntarily to avoid a relapse due to her pregnancy. The patient demonstrates limited coping skills to address relapse triggers and urges. She is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient lives with her husband and parents. She is unemployed due to drinking on the job. She has experienced substantial legal issues related to her drinking problem. She is currently in her second trimester of pregnancy. The patient reported ongoing severe PTSD symptoms that she has been unable to manage at home without resorting to alcohol usage. The patient has been able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment makes recovery unlikely and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, RTC services were and are medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were and are 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.