Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 31-year-old male who was admitted to a residential treatment center on 12/22/21 
and presented for an admission assessment. The patient has requested reimbursement for ASAM 
Level 3.5, clinically managed high-intensity residential services (adult criteria), from 12/29/21 
through 12/31/21. The Health Insurer has denied this request and reported that the services at issue 
were not medically necessary for the treatment of this patient. This denial is the subject of this 
appeal and determination. The physician reviewer found that per American Society of Addiction 
Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC services from 
12/29/21 through 12/31/21. 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 records 
support a score of 0. The patient was admitted to the residential treatment center following 
detoxification. The patients withdrawal needs were safely managed in a Level 3.5 setting. For 
dimension 2, the records support a score of 0. The patient had no acute medical problems during 
his treatment and did not require 24-hour medical or nurse monitoring. For dimension 3, the 
records support a score of 1. The patient reported a history of PTSD. The patient was not on any 
psychotropic medications when he entered the facility and did not endorse suicidal or homicidal 
ideation, psychosis, major depression, panic attacks, severe anxiety, or mania during the period in 
question. This criterion was not met. For dimension 4, the records support a score of 1. The records 
showed that the patient participated in individual treatment, equine therapy, 12-step work, and 
group sessions. He reported that he was working on his mental health. This criterion was not met. 
For dimension 5, the records support a score of 2. The records noted two prior residential treatment 
center attempts. The patients first attempt was at age 15, resulting in a relapse when the patient 
went to college. The second attempt was in 2018 and the patient relapsed six years later. The 
patient reported that the relapse was due to loneliness. The patient was able to stay clean and sober 
for six years and relearned relapse-prevention tools while at the facility. The records reflected that 
the patient worked hard on recovery and was willing to step down to sober living to continue with 
a sober network and supports. This criterion was not met. For dimension 6, the records support a 
score of 1. The patient reported good family support and the patient agreed to step down to sober 
living to continue receiving support. He was aware of the sober network in his community and 
was not returning to an unsafe home or environment. This criterion was not met. Given these 
findings, the patient did not meet the six ASAM criteria for RTC services provided from 12/29/21 
through 12/31/21. Therefore, ASAM Level 3.5, clinically managed high-intensity residential 
services (adult criteria), from 12/29/21 through 12/31/21, were not medically necessary for the 
treatment of this patient.