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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for substance abuse residential treatment center (RTC) services at Rimrock Foundation. Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet 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 managed for withdrawal with valium. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had hypertension. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported symptoms of depression and anxiety, and reported using drinking to deal with his negative emotions. The patient was not suicidal or homicidal and was not noted to have functional deficits. He participated in group sessions. While the patients mental status was stable enough to permit participation, the records did not demonstrate that he was unable to control his use of alcohol and drugs with attendant probability of imminent danger, that he demonstrated repeated inability to control his impulses to use alcohol and other drugs and was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, that he demonstrated antisocial behavior patterns, that he had significant functional deficits of a pervasive nature that were likely to respond to staff interventions and primarily habilitative in focus, or that he had 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 himself to the RTC voluntarily due to the effects of his alcohol use on his relationships. He participated in his treatment. The records did not show that the patient had limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between his substance use, mental health, or life problems and his impaired coping skills and level of functioning, demonstrated passive or active opposition to addressing the severity of his addiction problem, required structured therapy and a 24 hour programmatic milieu because motivational interventions had not succeeded at less intensive levels of care, had a perspective impairing his ability to make behavioral changes without repeated, structured motivational interventions, expressed little to no interest in changing, or attributed his alcohol, drug or mental health problem to other persons or external events. This criterion was not met. For dimension 5, the patient was drinking up to four bottles of wine daily for the past two weeks. The patient was noted to have good insight into his alcohol use disorder and need for treatment. He was treated for cravings for alcohol with naltrexone. He did not endorse suicidal or homicidal ideation, did not have a history of attempted suicide or aggression, and was not at probability of harm to self or others. The records did not note a lack of insight into the benefits of continuing care and lack of commitment to treatment, inability  to control use of alcohol or drugs with attendant probability of harm to self or others, 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, in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, continued use of alcohol or drugs despite recent active participation in treatment at a less intensive level of care, or a lifetime history of repeated incarceration. This criterion was not met. For dimension 6, the patient lived with his wife and children in a sober household and worked as a firefighter. The records did not note that the patient was living in an environment characterized by a moderately high risk of neglect, abuse, or substance use so endemic that recovery was assessed as unachievable at a less intensive level of care, a social network including regular users of drugs such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care, a social network characterized by significant social isolation and withdrawal such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care, a social network involving living a regular user, addicted user, or dealer of alcohol or other drugs, or an inability to cope, for even limited periods of time outside of 24-hour 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, substance abuse RTC services at Rimrock Foundation were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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.