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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) (ASAM 3.5) level of care. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services. Findings:  The physician reviewer found that For dimension 1, the patient underwent management for alcohol withdrawal earlier in her stay. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient has a history of hyperthyroidism. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had symptoms of depression. She reported drinking heavily for the past two years despite negative consequences of blackouts, emergency room visits, and falls resulting in a concussion and necessitating surgery. She was unable to refrain from drinking despite participating in an IOP program. While driving under the influence (DUI), she struck a cyclist causing injury. She continued to have cravings and lacked insight into her condition. The patients mental status was stable enough to permit participation, she demonstrated a repeated inability to control her impulses to use alcohol, and she was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient was admitted voluntarily for treatment after being bailed out of jail. She had four felony charges resulting from DUI, hitting a cyclist, and fleeing the police. She reported drinking problematically for the past two years with day drinking, blackouts, and injuries to herself and others. She participated in an IOP program but relapsed immediately upon graduation. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care. For dimension 5, the patient had completed an IOP program prior to RTC admission, but it was ineffective as the patient relapsed the day that the program ended and continued to drink up until her arrest for the DUI. Despite recent, active, participation in treatment at a less intensive level of care, the patient continued to use alcohol with imminent serious consequences and was at high-risk of continued alcohol use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient reported drinking heavily on a daily basis for the past two years, resulting in significant injuries to herself and to others. She was unable to work due to her addiction. She finished an IOP treatment program but relapsed the day that it ended. The patient did not have the coping skills to manage without using alcohol in the home environment. The patient was unable to cope, for even limited periods of time, outside of 24-hour care and required staff 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. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, RTC (ASAM 3.5) level of care was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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.