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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 admitted to the RTC facility after spending one week in jail. He declined to be placed on a withdrawal management medication protocol despite having withdrawal symptoms of anxiety, insomnia, restlessness, diaphoresis, and poor concentration. Based on the clinical findings, the patient met the ASAM requirement that his withdrawal needs could be met in Level 3.5 setting. For dimension 2, the patient has a history of asthma. He was repeatedly hypertensive throughout his admission. However, these biomedical problems were stable. Based on the clinical findings, the patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patients mental status was stable enough to permit participation. The patient denied any psychiatric history while his mother reported that he was placed on a 5150 hold in 2017 after an aggressive outburst. She also reported that he had seen a psychiatrist since 2013 for aggression. The provider noted concern for bipolar disorder and intellectual disability. His parent reported that there have been ongoing problems with aggression. The patient also mentioned that uses alcohol to manage the voices in his head. The patient has been living at home with his parents, is unemployed, and without friends. Based on clinical findings, the patient meets the criterion of having significant functional deficits, which are likely to respond to staff interventions. These symptoms and deficits are sufficiently severe that the patient was not likely to maintain mental stability or abstinence if treatment was provided in a non-residential setting. For dimension 4, the patient admitted that he came to treatment because of an assault that occurred while he was intoxicated. He voiced that he did not believe he had an alcohol problem and that he could quit drinking at any time. He was in the precontempative stage of change. He demonstrated poor insight and awareness for his need for treatment. He has been drinking alcohol every day for the past 10 years. Despite prior legal issues that stemmed from his issues with alcohol, he did not see his alcohol usage has a problem. He meets this requirement because of the intensity and chronicity of the addictive disorder, he has limited insight and awareness of the need for continuing care or the existence of his substance use disorder. For dimension 5, the patient reported drinking one pint daily for the past 10 years. He admitted to significant cravings to drink but declined any medications to decrease cravings. The patient did not recognize relapse triggers and lacked insight into benefits of continuing care, and was therefore not committed to treatment. He admitted to using drinking in order to manage the voices in his head. For dimension 6, the patient is single, unemployed, and lives with his parents. He does not have any friends or social outlets. He does not have any hobbies or recreational outlets. Without the structured environment provided in the 3.5 RTC setting, this patients risk of relapse was deemed imminent. Based on clinical findings, the patient met the six ASAM dimensions to support the medical necessity of the RTC services at issue. For these reasons, the RTC level of care services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 expertise 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.