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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for RTC services from 9/18/20 forward. 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 no longer in acute withdrawal. Medically, his vital signs were stable, and he does not have a history of any complicated withdrawal that would necessitate 24-hour medical supervision. Prior to admission, the patient completed an inpatient detoxification to address his withdrawal symptoms. The patients withdrawal needs could be safely managed in a Level 3.5 setting. For dimension 2, the patient did not have any reported biomedical conditions. The patients liver function test results have been trending downward. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patients mental status was assessed as sufficiently stable to permit the patient to participate in therapeutic interventions provided at this level of care and to benefit from treatment. He is participating in groups and motivated to seek sobriety. The provider reports that the patient is benefitting from treatment. The patient does not have a psychiatric condition that requires stabilization, repeated inability to control impulses to use substances, antisocial behavior, significant functional deficits, or a concomitant personality disorder. For dimension 4, the patient is motivated to change, and he has benefited from support and structure. However, the patient does not require structured therapy in a 24-hour programmatic milieu, and he does not show that his perspective impairs his ability to make behavior changes without repeated clinically directed motivational interventions. For dimension 5, the patient remains at high risk for relapse. The patient is in imminent danger of relapse or continued use, with dangerous emotional, behavioral or cognitive consequences, as a result of a crisis situation. For dimension 6, the patients grandmother is involved and supportive of his treatment. The patient reportedly has some conflict with his mother, and his college roommate drinks alcohol. The records do not support that the patient has been unable to cope for limited periods of time outside of 24-hour care. Given these findings, the patient does not meet the six ASAM dimensions for RTC level of care services. Therefore, the RTC services were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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.