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

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 had no signs or symptoms of withdrawal. The patients last use of alcohol was on July 2020 and she was treated with withdrawal management until she stepped down to RTC services on mid-July of 2020. For dimension 2, the patients biomedical problems were stable and did not require medical or nurse monitoring and the patient was capable of administering any prescribed medications. The records document a previous episode of pancreatitis, elevated transaminases in a pattern consistent with alcoholic hepatitis, and previous episode of alcoholic ketoacidosis. She is at risk of repeated episodes of increasing severity if she continues drinking. For dimension 3, the patients mental status was 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. She was diagnosed with generalized anxiety disorder and started on Lexapro in addition to taking gabapentin. The provider noted that the patient was emotionally fragile and was prone to crying spells. The patient participated in groups. The patient demonstrated through generalized anxiety, an inability to maintain stable behavior over a 24-hour period without the structure and support of a 24-hour setting. For dimension 4, the patient acknowledged the existence of a psychiatric condition. She recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change. The patient was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient demonstrated limited coping skills to address relapse triggers. She was thus in imminent danger of relapse with dangerous consequences and needed 24-hour structure to help her apply recovery and coping skills. The patient had one prior attempt at sobriety, and she was sober for three months prior to relapse. She then started binge drinking until her episode of ketoacidosis. She was noted to have a lack of awareness regarding triggers and difficulty employing coping skills independently. For dimension 6, the patient was able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue community activities. The patients social network was characterized by significant social isolation and withdrawal, leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting. The patient was noted to be socially isolated except for her husband. She has been unemployed since the pandemic and has a lack of structured activity. These findings demonstrate that the patient met the six ASAM dimensions for Level 3.1 RTC services. Therefore, the RTC level of care services were medically necessary for treatment of this patient.