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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services (ASAM Level 3.7). Findings:  The physician reviewer found that (ASAM) criteria this patient did not met Level 3.7 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. Admission is appropriate when specifications are met in at least two of the six dimensions, and at least one of which is from dimensions 1, 2, or 3. This patient does not meet any of the criteria for dimensions 1, 2, 3, 4, 5, or 6. For dimension 1, the patients last drink of alcohol was on the date of admission. She was placed on a Librium protocol with Clinical Institute Withdrawal Assessment (CIWA) scores ranging from 6-8. The patient does not have severe withdrawal that needs 24-hour nursing and medical monitoring or active treatment. Based on these findings, the patient did not meet the requirements for this dimension. For dimension 2, the patient does not have any documented biomedical problems. The patient was medically stable at the time of this admission. The patient does not meet criteria of interaction of the patients biomedical condition and continued alcohol use places the patient at significant risk of serious damage to physical health or current biomedical condition requires 24-hour nursing and medical monitoring or active treatment, but not the full resources of an acute care hospital. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 3, the patient previously underwent treatment for depression as an outpatient. During RTC admission, the patient was not suicidal, homicidal, or psychotic. There is a lack of documentation suggesting that she posed a risk of harm to herself or others if not contained in a 24-hour structured environment. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 4, the patient was admitted voluntarily for treatment after she was unable to stop drinking while doing an IOP program. The patient demonstrated insight into her addictive disorder diagnosis, and she was not in need of intensive motivating strategies only available in a 24-hour structured and medically monitored setting, or ongoing 24-hour psychiatric monitoring to assure follow through with the treatment regimen. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 5, this is the patients second attempt at treatment after she was unsuccessful at the IOP level of care. She continued to drink despite IOP program participation. The records do not support that the patient posed a serious risk of harm to self or others in the absence of 24-hour monitoring and structures support found in a medically monitored setting. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 6, the patient lives alone and shares custody of her child with the father. There are notes indicating that the patient had her visitation rights suspended due to alcohol usage. The patient was on medical leave from her job, and she was unable to function as a parent due to her drinking. The patient reported that she continued drinking while in an IOP program prior to admission to the RTC. Given these findings, the patient did not require continuous medical monitoring while addressing her substance use due to her current living situation. The patient was able to cope outside of 24-hour care and she did not require staff monitoring to learn to cope with dimension 6 problems before being transferred safely to a less intensive setting. Based on these findings, the patient did not meet the requirements for this dimension. For these reasons, the patient did not meet the six ASAM dimensions for Level 3.7 RTC services. Moreover, the RTC services were not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, the RTC services (ASAM Level 3.7) 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 with subspecialty certification 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.