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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services and Partial Hospitalization Program (PHP) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.5 criteria for Residential Treatment Center services. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. Treatment records reflect that the patient had been treated with a Librium taper. Records reflect that the patient had mild withdrawal symptoms of irritability and anxiety. Based on clinical findings, the patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient had alcoholic liver disease, hypertension, and GERD. His medical problems were stable during his admission. The patients biomedical problems were therefore stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient had a diagnosis of generalized anxiety disorder. He was noted to have significant problems with anger and irritability in groups during his treatment. He had conflicts with peers and with staff with disruptive behavior and outbursts of anger. The patients mental status permitted participation, and he had significant functional deficits which were likely to respond to staff interventions. These symptoms were sufficiently severe that the patient was not likely to maintain abstinence if treatment was provided in a non-residential setting. The functional deficits were of a pervasive nature and included residual psychiatric symptoms and inadequate anger management skills.For dimension 4 - Readiness to Change. The patient agreed to an admission after his fiance threatened to leave him and his son begged him to get help. He had been drinking 10-15 vodka drinks on a daily basis for years and described being on a `bender` for the prior six months. He was assessed as being in the contemplative stage of change. The patient's perspective impaired his ability to make behavior changes without the repeated, structured, and clinically directed motivational interventions which could only be delivered in a 24-hour milieu.For dimension 5 - Relapse, Continued Use, or Continued Problem Potential. The patient had not had a consistent period of sobriety longer than a few days since he started drinking at the age of 15. He had tried to quit on his own and was unsuccessful. He had never been in formal treatment. He was noted on intake to be in denial about the extent of his alcohol problem and was resistant to treatment. The patient did not recognize his relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment.For dimension 6 - Recovery Environment. The patient was living with his fiance and adult children. He had been unable to stop drinking on his own on multiple occasions. His social network was composed of other drinkers. The patient's social network included regular users of alcohol such that his recovery goals were unachievable at a less intensive level of care, and he was unable to cope, for even limited periods of time, outside of 24-hour care.Using the ASAM level 3.5 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.5 treatment. Accordingly, the Residential Treatment Center services at issue were medically necessary for the patients medical condition.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient also met Level 2.5 criteria for Partial Hospitalization Program (PHP) services. Of note, problems in dimensions 1, 2 and 3 are not necessary for admission to a level 2.5 program.For dimension 4 - Readiness to Change. The patient was noted to have doubts about his ability to maintain sobriety. He expressed feeling hopeless about his ability to remain sober from alcohol and that he was not ready to stop drinking. Staff noted that the patient was resistant to treatment and had minimal engagement in his recovery process. The patient was noted to want to leave treatment and was noted to be ambivalent about needing treatment. He was noted to minimize his use of alcohol, and he planned on drinking wine with his friends on a weekly basis. The patient's perspective and lack of impulse control inhibited his ability to make behavioral changes without repeated, structured, clinically directed motivational interventions.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. Prior to entering formal treatment, the patient had tried multiple times to quit on his own and was unable to maintain sobriety for longer than a couple days. The patient stated that he wanted to leave treatment and that he was ambivalent about his need for treatment. The patient was noted to have no insight into his relapse triggers. Notes reflect that there was a high likelihood that the patient would relapse without close outpatient monitoring and structured therapeutic services, as indicated by his lack of awareness of relapse triggers or ambivalence toward treatment.For dimension 6 - Recovery Environment. The patient had a social network that consisted of other drinkers. He also lived with his fiance, whom he found to be a source of stress, as she had been threatening to leave him. The patient had been drinking heavily for decades and this was his first attempt at formal treatment. Under these circumstances, continued exposure to the patient's current living environment rendered his recovery unlikely. The patient lacked the skills necessary to maintain an adequate level of functioning without the services of a Level 2.5 program.Under these circumstances, the patient met the required three criteria for medical necessity and therefore qualified for ASAM Level 2.5 treatment. Accordingly, the Partial Hospitalization Program (PHP) services at issue were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.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.