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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.1 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 treated for withdrawal during hospitalization and the records indicate that he has been able to remain sober. The patients withdrawal needs can be safely managed in a Level 3.1 setting. For dimension 2, the patient has cirrhosis and would like to be eligible for a liver transplant. The patient reports that he has remained sober while in the IOP. 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 bipolar disorder. He is being treated with quetiapine and participating in IOP. The records suggest that the patients psychiatric status is stable. The patients mental status is 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. The patients psychiatric condition is stable, and he is assessed as having minimal problems in this area. For dimension 4, the patient has agreed to participate in the IOP and did not want a more intensive day program due to his work responsibilities. He has been participating in treatment. The provider noted that the patient has been motivated  and able to maintain sobriety at the current level of care. The patient does not meet any of the criteria for admission to Level 3.1. For dimension 5, the patient reported that he has been using alcohol since age 18 with problematic usage since age 25. He has experienced a continuous pattern of alcohol usage throughout this time with only 2.5 months of sobriety. However, he has maintained sobriety for 34 days while participating in the IOP. He has demonstrated adequate coping skills to address relapse triggers even through high-risk events. The patient continues to express motivation to stay in recovery and does not need 24-hour support to maintain his recovery process. The patient does not meet any of the criteria for admission to Level 3.1.For dimension 6, the patient is living with his parents while his wife and child live with her parents. He is employed and has legal consequences of his alcohol abuse. He has a sober support system through his family and through the IOP. There is no mention of abuse or high-risk social contacts. The patient does not meet any of the criteria for admission to Level 3.1.Given these findings, the patient does not meet the six ASAM dimensions for RTC services. The requested RTC services are not in accordance with the generally accepted standards of mental health and substance use disorder care and are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the requested RTC services are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services 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.