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. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does 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 treated for alcohol withdrawal earlier in his course of treatment. The patients withdrawal needs can be safely managed in a Level 3.5 setting.For dimension 2, the patient has chronic back pain. 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 been diagnosed with depression, anxiety, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD). He is not suicidal or homicidal. He does not have history of overdose, suicide attempts, or aggressive behaviors toward others. He participated in groups. The patients mental status has been 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. However, the patient does not meet any of the other qualifying criteria including unable to control his use of alcohol and drugs with attendant probability of imminent danger, demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, or demonstrates antisocial behavior patterns. The records do not document any significant functional deficits, which are likely to respond to staff interventions of pervasive nature requiring treatment that is primarily habilitative in focus and the patient does not have any reported concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 4, the patient admitted himself for treatment voluntarily after relapsing shortly after a previous treatment admission. The patient has been able to admit that he has a substance use disorder, and he has been able to identify his triggers. The patient realized that he could not return home to live with his mother who drinks alcohol, and he was willing to go to sober living environment. The records do not establish limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between substance use, mental health, life problems and impaired coping skills and level of functioning, often blaming others for his addiction problems, or passive or active opposition to addressing the severity of his addiction problem. The patient does not require structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care, his perspective does not impair his ability to make behavior changes without repeated, structured motivational interventions, and the patient does not attribute his alcohol, drug or mental health problem to other persons or external events. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 5, the patient was drinking a fifth of vodka and using cocaine daily for the past two years. The patient has recognized the need for treatment and continuing care. The patient denies suicidal and homicidal ideation. The patient does not show a lack of insight into benefits of continuing care or an inability to control use of alcohol or drugs with attendant probability of harm to self or others. The records do not support that the patient is in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, despite recent active participation in treatment at a less intensive level of care, the patient continues to use alcohol or drugs, or that the patient demonstrates a lifetime history of repeated incarceration. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 6, the patient was previously living with his mother who has an alcohol use disorder and drinks in the house. The patient has acknowledged that he cannot return to the home due to his mothers drinking and he is willing to go to a sober living environment. The patients social network involves living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs or the patients living environment is so highly invested in alcohol and/or other drugs that his recovery goals are assessed as unachievable. Given these findings, the patient does not meet Level 3.5 RTC criteria for dimensions 3, 4, or 5. The ASAM criteria require adult patients to meet all six dimensions to support RTC services. Moreover, the RTC services are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the RTC services (ASAM level 3.5) 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.