Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 36-year-old female who was admitted to a residential treatment center (RTC) on 
8/21/22. The patient has requested reimbursement for substance abuse inpatient treatment 
from 8/26/22 through 9/14/22. 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 8/26/22 through 9/14/22. 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 assessed for alcohol withdrawal earlier in her 
treatment stay and managed with phenobarbital. She reported mild symptoms of PAWS. The 
patients withdrawal needs were safely managed in a Level 3.5 setting. This criterion was met. 
For dimension 2, the patient did not have significant medical problems. The patients biomedical 
problems were stable and did not require 24-hour medical or nurse monitoring.  This criterion 
was met. For dimension 3, the patient had diagnoses of major depressive disorder and anxiety. 
She endorsed suicidal ideation on 8/16/22 due to her fiance breaking up with her but denied 
suicidal ideation as of 8/21/22. The records did not note a history of overdose, suicide attempts, 
or aggressive behaviors toward others. She participated in group sessions. The patients mental 
status was stable enough to permit participation, but the records did not indicate that she was 
unable to control her use of alcohol or was in imminent danger of relapse, with attendant 
likelihood of harm to self, others, or property, demonstrated antisocial behavior patterns, had 
significant  functional  deficits  of  a  pervasive  nature  requiring  treatment  that  is  primarily 
habilitative in focus that were likely to respond to staff interventions, or concomitant personality 
disorders of such severity that the accompanying dysfunctional behaviors provided opportunities 
to promote continuous boundary setting interventions. This criterion was not met. For dimension 
4, the patient admitted herself for treatment voluntarily. She was able to admit that she had an 
alcohol use disorder, participated in her treatment, and expressed interest in changing.  The 
records did not indicate that the patient had limited insight and little awareness of the need for 
continuing care, marked difficulty in understanding the relationship between substance use, 
mental  health,  or  life  problems  and  her  impaired  coping  skills  and  level  of  functioning, 
demonstrated passive or active opposition to addressing the severity of her addiction problem, 
or  required  structured  therapy  and  a  24  hour  programmatic  milieu  because  motivational 
interventions had not succeeded at less intensive levels of care. The patient did not have a 
perspective that impaired her ability to make behavior changes without repeated, structured 
motivational interventions, express little to no interest in changing, or attribute her alcohol, drug 
or mental health problem to other persons or external events. This criterion was not met. For 
dimension 5, the patient reported drinking at least eight ounces of liquor daily. She recognized 
the need for treatment and continuing care. The patient did not have a history of suicidal or 
homicidal ideation, suicide attempts or aggression. She did not endorse cravings. The records did  not indicate that the patient lacked insight into benefits of continuing care and was therefore not 
committed to treatment, was unable to control use of alcohol or experiencing cravings with the 
situation posing an imminent danger of harm to self or others in the absence of close 24-hour 
monitoring  and  structured  support,  was  in  imminent  danger  of  relapse  with  dangerous 
emotional, behavioral, or cognitive consequences as a result of a crisis situation, continued to 
use alcohol despite recent active participation in treatment at a less intensive level of care, or 
demonstrated a lifetime history of repeated incarceration. This criterion was not met. For 
dimension 6, the patient lived with her father, who did not drink, and her ex-fiance, who moved 
out of the residence during the patients treatment stay. She appeared to be somewhat socially 
isolated and to lack sober supports other than her father. The patient's social network was 
characterized by significant social isolation or withdrawal such that recovery goals were assessed 
as unachievable at a less intensive level of care.  This criterion was met.  Given these findings, the 
patient did not meet the six ASAM criteria for RTC services provided from 8/26/22 through 
9/14/22. Accordingly, substance abuse inpatient treatment from 8/26/22 through 9/14/22 was 
not medically necessary for treatment of this patient.