Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 38-year-old male who presented for a biopsychosocial assessment on 5/9/22. 
The  patient  has  requested  reimbursement  for  Level  3.5  clinically  managed  high-intensity 
residential services (adult criteria) from 5/25/22 through discharge. The physician reviewer found 
that Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 
criteria for RTC services from 5/25/22 through discharge. 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 underwent management for alcohol withdrawal 
earlier in his treatment stay. The patients withdrawal needs were safely managed in a Level 3.5 
setting. For dimension 2, the patient had hypertension, elevated transaminases, and a twenty 
pound weight loss. The patients biomedical problems were stable and did not require 24-hour 
medical or nurse monitoring.  For dimension 3, the patient  had symptoms of anxiety and 
depression. He reported drinking 750 mL of whiskey daily. He had tried to reduce his drinking by 
switching to seltzers, resulting in an alcohol withdrawal seizure in January 2022.  The patient was 
reluctant to remove alcohol from his home. The patients mental status was stable enough to 
permit  participation,  he  demonstrated  a  repeated  inability  to  control  his  impulses  to  use 
substances, and he was in imminent danger of relapse with attendant likelihood of harm to self. 
The resulting level of dysfunction was of such severity that it precluded participation in treatment 
in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the 
patient was admitted voluntarily for treatment after being unable to reduce or stop drinking on 
his own and having an alcohol withdrawal seizure in January 2022. He reported problematic 
drinking for the past four years and drinking 750 mL of whiskey daily. The patient appeared 
ambivalent about his need for treatment as he did not want to remove alcohol from his house. 
Due to the intensity and chronicity of the addictive disorder, the patient had limited insight and 
little awareness of the need for continuing care or the existence of his substance use and need 
for treatment, and thus had limited readiness to change. For dimension 5, this was the patient's 
first attempt at treatment. He reported drinking 750 mL of whiskey daily.  He was assessed as not 
having the skills to manage his urges to drink alcohol and was resistant to fully removing alcohol 
from the house. His drinking was so severe that he had an alcohol withdrawal seizure in January 
2022. The patient did not recognize relapse triggers and lacked insight into the benefits of 
continuing care and was therefore not committed to treatment. His continued alcohol use posed 
an imminent danger of harm to self or others in the absence of 24-hour monitoring and 
structured support. For dimension 6, the patient lived with his wife, who was a social drinker. He 
was reluctant to remove alcohol from the home. He consistently drank alcohol heavily when in 
his home environment. The patient was unable to cope, for even limited periods of time, outside 
of 24-hour care and required monitoring to learn to cope with problems before being transferred 
safely to a less intensive setting. Given these findings, the patient met the six ASAM criteria for  RTC services provided from 5/25/22 through discharge. Accordingly, Level 3.5 clinically managed 
high-intensity residential services (adult criteria) from 5/25/22 through discharge were medically 
necessary for treatment of this patient.