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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any of the residential treatment care (RTC) (ASAM Level 3.5) services. Findings:  The physician reviewer found that American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC services from 8/16/21 and forward. 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 managed with naltrexone for cravings. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient has asthma. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring. For dimension 3, the patient was being treated for major depressive disorder and generalized anxiety disorder. She was undergoing medication adjustments and reported side effects and difficulties with dosage increases. The patient was not suicidal or homicidal, and participated in group sessions. The patients mental status was stable enough to permit participation. The records did not indicate that she was unable to control her use of alcohol or was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrated antisocial behavior patterns, had significant functional deficits of a pervasive nature requiring treatment that is primarily habilitative in focus that were likely to respond to staff interventions, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provided opportunities to promote continuous boundary setting interventions. This criterion was not met.For dimension 4, the patient admitted herself for treatment voluntarily under pressure from her parents. She initially reported not being interested in being sober long-term or in participating in treatment. Notes reported that the patient was actively participating in treatment and developed increased insight into her addiction. The records did not indicate that the patient had limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between substance use, mental health, or life problems and her impaired coping skills and level of functioning, demonstrated passive or active opposition to addressing the severity of her addiction problem, or required structured therapy and a 24 hour programmatic milieu because motivational interventions had not succeeded at less intensive levels of care. The patient did not have a perspective that impaired her ability to make behavior changes without repeated, structured motivational interventions, express little to no interest in changing, or attribute her alcohol, drug or mental health problem to other persons or external events. This criterion was not met. For dimension 5, the patient reported drinking up to two bottles of wine daily for one and a half years since the COVID pandemic. She reported participating in an IOP program and was sober for most of June but relapsed later in the month due to not getting the job. The patient did not have a history of suicidal or homicidal ideation, suicide attempts or aggression. She was on medications for cravings and reported not having cravings. The records did not indicate that the patient lacked insight into benefits of continuing care and was therefore not committed to treatment, was unable to control use of alcohol or experiencing cravings with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, continued to use alcohol despite recent active participation in treatment at a less intensive level of care, or demonstrated a lifetime history of repeated incarceration. This criterion was not met.  For dimension 6, the patient has stable housing. She is currently unemployed and has worked as an attorney in the past. The records did not indicate that the patient was living in an environment characterized by a moderately high risk of neglect or of endemic substance abuse, or that the patient was unable to cope for even limited periods of time, outside of 24-hour care. The patient did not have a social network including regular users or dealer of substances, or have a social network characterized by significant social isolation and withdrawal, such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. This criterion was not met.Given these findings, the patient did not meet the six ASAM criteria for RTC services. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, RTC services were not and are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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.