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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) RTC services, and (2) intensive outpatient program services. At issue is whether RTC services were medically necessary for the treatment of this patient. Per the American Society of Addiction Medicine (ASAM) criteria this patient met 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 noted to have withdrawal symptoms of nausea, agitation, diaphoresis, and anxiety. He was treated with a taper for detoxification. The patients withdrawal needs were safely managed in level 3.5 setting.  For dimension 2, the patient reported low back pain. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoringFor dimension 3, the patient had diagnoses of major depressive disorder and generalized anxiety disorder. The records noted that the patient reported hopelessness, anxiety, and depression while in treatment. He reported drinking a bottle of vodka daily to self-medicate. He had unsuccessfully attempted detoxification at home with benzodiazepines. He had legal issues related to his drinking. The patients mental status was stable enough to permit participation, he demonstrated a repeated inability to control his impulses to use alcohol, and he was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient had unsuccessfully attempted detoxification at home with benzodiazepines. The patient had significant issues due to his drinking, including legal issues, custody issues, and professional licensing issues. He was reported to minimize his alcohol use. His was receiving daily assistance from his mother for basic activities of daily living. The patient reported inability to manage his stressors without drinking. 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 not had a consistent period of sobriety in the last five years. He had unsuccessfully attempted detoxification at home with benzodiazepines. He was noted be in denial about the extent of his problems with alcohol. 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 lived alone next door to his mother, who assisted him daily with activities of daily living. He had significant legal issues and was unable to manage his psychosocial stressors without resorting to alcohol. The patient was assessed as unable to cope, for even limited periods of time, outside of 24-hour care.Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, the RTC services were medically necessary for treatment of this patient.At issue is whether intensive outpatient program (IOP) services were and are medically necessary for the treatment of this patient.Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 2.5 criteria for IOP 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.Dimensions 1, 2, and 3 are not required for admission to a Level 2.5 program.For dimension 4, the patient was stepping down to IOP from RTC level of care. He required this level of care given his fears regarding his ability to cope with stressors without alcohol and reported feelings of being overwhelmed by his legal, financial, and personal issues. He reported feeling a loss of motivation to continue his sobriety. He was reported to not be completing assignments and showing a reduced level of engagement in his recovery process.  The patient's perspective and lack of impulse control inhibited his ability to make behavioral changes without repeated, structured, clinically directed motivational interventions. For dimension 5, the patient has demonstrated relapse triggers and significant continued use potential. Prior to entering residential treatment, he had attempted detoxification at home with benzodiazepines, but was unable to achieve sobriety. He reported feeling overwhelmed by his legal issues and reported a loss of motivation. There is a high likelihood that the patient will relapse without close outpatient monitoring and structured therapeutic services, as indicated by his lack of awareness of relapse triggers or ambivalence toward treatment.For dimension 6, the patient lives alone next door to a parent who has enabled his drinking. He has multiple legal issues. He reported drinking heavily for the past five years and is stepping down from his first residential treatment at RTC level of care. This episode of sobriety is his longest. Continued exposure to the patient's current living environment will render recovery unlikely. The patient lacks the skills necessary to maintain adequate level of functioning without the services of a Level 2.5 program. Given these findings, the patient met the six ASAM dimensions for IOP services during the period under review. Therefore, the IOP services provided were and are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified 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.