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 residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 underwent withdrawal management at the inpatient facility prior to release to the RTC. The patients withdrawal needs can be safely managed in Level 3.5 setting.For dimension 2, the patient has medical problems of seizure disorder and hypertension. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications.  For dimension 3, the patient has bipolar disorder, most recent episode manic with psychotic features. His wife had a restraining order placed against him due to his aggressive and threatening behaviors. He has been using alcohol to manage his manic symptoms and to control his anxiety. He was noted to have tremendous difficulty with managing irritability and impulsivity, and he was preoccupied with religion. He has demonstrated difficulty tolerating groups due to his irritability and suspiciousness of others. The patients mental status has been assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has significant functional deficits which are likely to respond to staff interventions. These symptoms are sufficiently severe that the patient is not likely to maintain abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus and do not require medical management. They may include, but are not limited to, residual psychiatric symptoms. For dimension 4, the patient was voluntarily admitted to RTC after stepping down from the inpatient level of care for a manic episode with psychotic features. His drinking increased to 19 beers per day and he became more aggressive at home, which culminated in a restraining order. The patient was preoccupied with religion. The patients perspective impairs his ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable him to develop insight into the role he plays in his substance use and mental condition, and enable him to make behavioral changes which can only be delivered in a 24-hour milieu. For dimension 5, the patient has been using alcohol since age 20. He has a history of several prior attempts at sobriety and he was sober for about one year in 2010. He is currently being stabilized for a manic episode of his bipolar disorder to help with his impulsivity and mood stability. He continues to have low frustration tolerance and he has been easily triggered by others in group. The patients psychiatric condition is stabilizing. However, despite his best efforts, the patient has been unable to control his use of alcohol and antisocial behaviors, with attendant probability of harm to self or others. The patient has limited ability to interrupt the relapse process or continued use, or to use peer supports when at risk for relapse to his addiction and mental disorder. His continued substance use poses an imminent danger of harm to self and others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient was living with his wife, but she has a restraining order against him, and he is living with his father. He is unemployed and he repotted drinking 18 beers on a daily basis. He continues to be easily confused, distracted and easily agitated such that he has been unable to perform simple tasks while in the RTC. The patient has been unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with Dimension 6 problems before he can be safely transferred to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services were and are medically necessary for 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 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.