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) 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. Applying the ASAM framework, this patient met the criteria for Level 3.5 RTC services. For dimension 1, the patients withdrawal were safely be managed in this 3.5 RTC level of care. He was started on a Librium taper and his protracted withdrawal symptoms did not need a higher level of care. For dimension 2, the patients biomedical conditions include cognitive problems described as significant problems with short-term and immediate memory, constipation, and hypertension. The patients biomedical issues were not severe enough to warrant inpatient treatment but were sufficient to distract from treatment and recovery efforts. The patients hypertension and neurocognitive deficits required medical monitoring, which was safely provided at this level of care, and through an established arrangement with another provider as evidenced by transfer to the emergency department for constipation during his stay. For dimension 3, the patients mental status was sufficiently stable to permit his participation in the therapeutic interventions provided at the Level 3.5 of care and to benefit from treatment. The patient has significant functional deficits, which were likely to respond to staff interventions. These symptoms and deficits, when considered in the context of the patients home environment, were sufficiently severe that the patient was not likely to maintain mental stability if treatment was provided in a non-residential setting. The patient was noted to have uncontrolled hypertension and well-documented neurocognitive deficits which interfered with his insight and judgment. The patients functional deficits were pervasive and required treatment that is primarily habilitative in focus, but do not require medical monitoring or management. These symptoms include chronic addictive disorder managed with Naltrexone for cravings, marginal neurocognitive functioning and poor impulse control. His poor cognitive functioning, affect regulation, and insight as well as continued cravings required active monitoring provided in this 24-hour structured environment. For dimension 4, the patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care and such interventions were assessed as not likely to succeed in a less intensive level of care. The patient recognized that he needed treatment but his cognitive problems, uncontrolled hypertension, and risky behaviors, such as driving under the influence and potentially lethal cocktail of drugs and alcohol, placed him at imminent risk to public safety and harm to himself given his continued pattern of risk of harm. For dimension 5, the patients psychiatric condition was stabilizing. However, despite his best efforts, the patient was unable to control his use of substances with attendant possibility of harm to self or others. The patient had limited ability to interrupt the relapse process or continued use, or to use peer supports when at risk for relapse to his addiction. His continued substance use posed an imminent danger of harm to himself and others in the absence of 24-hour monitoring and structured support. His continued use of stimulants and alcohol posed a risk of hypertensive urgency, accidental overdose, and risky behaviors that posed risk to himself and others, including driving while under the influence. The patient reported that he was dry heaving and not eating for two weeks prior to admission. His blood pressure combined with his already suspect neurocognitive disorder placed him at significant risk without he Level 3.5 monitoring and care. For dimension 6, the patients social network was characterized by significant social isolation, such that recovery goals were assessed as inconsistently unachievable at a less restrictive level of care. The patient lives alone without support and he has been unable to control his urges to drink alcohol and use substances. The patient was unable to cope, even for limited periods of time, outside of 24-hour care and needed staff monitoring to learn to cope with Dimension 6 problems before being transferred to a less intensive setting. The patient reported that he could not make it through the day without alcohol. Given these findings, the patient met the six ASAM dimensions for Level 3.5 RTC services. Therefore, the RTC 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 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.