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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for subacute detoxification (ASAM 3.7) services. Findings:  The physician reviewer found that Per the American Society of Addiction Medicine (ASAM) framework this patient met the criteria for subacute detoxification (ASAM 3.7) level of care. Admission is appropriate when specifications are met in at least two of the six dimensions, at least 1 of which is dimensions 1, 2, or 3. 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 patients last drink was the day of admission and she was placed on five-day diazepam protocol with withdrawal monitoring. The patient reported withdrawal symptoms of tachycardia, agitation, and tremors. The patient required a withdrawal management protocol. For dimension 2, the patient does not have any reported medical problems. She was medically stable at the time of this admission. There was a lack of documentation of interaction of the patients biomedical condition and continued alcohol use places the patient at significant risk of serious damage to physical health, or that current biomedical condition requires 24-hour nursing and medical monitoring or active treatment, but not the full resources of an acute care hospital. Based on these findings, the patient does not meet the criteria for this dimension. For dimension 3, the patient has reported diagnosis of PTSD, generalized anxiety disorder, and major depressive disorder. The patient also has significant anxiety and agitation. The patients psychiatric condition was unstable and presented with symptoms that were interfering with abstinence, recovery, and stability to such a degree that the patient needed a structured 24-hour medically monitored environment to address recovery efforts. For dimension 4, the patient was admitted voluntarily for treatment of her alcohol use disorder after a four-day relapse and being evicted from her sober living environment. The patient was unable to stop drinking safely in the outpatient setting. The patient needed ongoing 24-hour psychiatric monitoring to assure follow through with the treatment regimen, and to deal with issues such as ambivalence about adherence to psychiatric medications and recovery program. For dimension 5, the patient relapsed after a 60-day period of sobriety. The patient subsequently lost her housing. The patient was binge-drinking for the four days prior to admission and she was unable to safely stop drinking in the community. The patient is noted to have a recent history of falling and sustaining a concussion and fractured rib while intoxicated. The patient was experiencing an acute psychiatric or substance use crisis, marked by intensification of symptoms of her addictive or mental disorder, which poses a serious risk of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient was in crisis due to losing her housing at the sober living facility after she relapsed on alcohol. The patient was unable to stop drinking safely on her own in the community. The patient was unable to cope, for even limited periods of time, outside of 24-hour care. She needed staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. This patient met the criteria for subacute detoxification (ASAM 3.7) level of care services since the specifications were met in at least two of the six dimensions, and at least one of which is from dimensions 1, 2, or 3. In addition, the subacute detoxification (ASAM 3.7) level of care services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the subacute detoxification (ASAM 3.7) level of care services were 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 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.