Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 33-year-old who presented for an admission assessment at a residential treatment 
center (RTC) on 4/24/22. The patient has requested reimbursement for ASAM Level 3.5 residential 
treatment services from 5/11/22 through 5/25/22. The Health Insurer has denied this request and 
reported that the services at issue were not medically necessary for the treatment of this patient. 
This denial is the subject of this appeal and determination. The physician reviewer found that per 
American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 
criteria for RTC services from 5/11/22 through 5/25/22. 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  records  support  a  score  of  0.  The  patient  completed 
detoxification and did not have acute withdrawal symptoms. The patients withdrawal needs were 
safely managed in a Level 3.5 setting. For dimension 2, the records support a score of 0. The 
patient was overweight. The patients biomedical problems were stable and did not require 24-
hour medical or nurse monitoring. For dimension 3, the records support a score of 0. The patient 
denied  a  history  of  depression,  anxiety,  suicidal  attempts,  psychosis,  mania,  psychiatric 
hospitalizations, eating disorders, and has never been diagnosed with any psychiatric disorder(s) 
or taken psychiatric medications. The patient did report some anxiety about being in treatment for 
the first time, however, he had not had enough time being clean and sober and his anxiety was 
situational. For dimension 4, the records support a score of 2. The patient was voluntarily admitted 
to treatment as he realized that his alcohol use was interfering with his job situation and his 
friendships. He realized that alcohol was a problem, participated in treatment, met with his 
therapist, and attended groups. For dimension 5, the records support a score of 2. The records did 
not document severe cravings. This was patient's first formal treatment for substance abuse. He 
had tried to stop drinking in the past on his own but did not have the relapse prevention skills that 
he learned in treatment. He reported that alcohol was interfering with his friendships and his 
vocation. For dimension 6, the records support a score of 2. The patient lived with a roommate 
who used alcohol occasionally and used cannabis. However, the patient reported that he wanted to 
return home and attend church for support. The records noted that the patients friends expressed 
concerns about the patient's drinking and that one had encouraged him to go to treatment. Given 
these findings, the patient did not meet the six ASAM criteria for RTC services provided from 
5/11/22 through 5/25/22. Accordingly, ASAM Level 3.5 residential treatment services from 
5/11/22 through 5/25/22 were not medically necessary for treatment of this patient.