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. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC services. Findings:  The physician reviewer found that 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, on admission, the patient had no ongoing signs or symptoms of withdrawal.  For dimension 2, the patient had complaints of shoulder pain related to a physical altercation with his brother prior to admission. He was medically stable. He was treated with non-steroidal anti-inflammatory medication. 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 patient admitted during his stay that he had suicidal ideation on admission at the time he initially presented for detoxification. However, by the date of denial, the patients mood was good, and he told his provider that he no longer needed antidepressant medication. The decision was made that the patient did not need this medication and that it would be tapered and discontinued. The patient expressed remorse for behavioral issues and events that transpired prior to admission. The patients mental status was assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. However, the patient did not meet any of the remaining requirements for this dimension such as the patients psychiatric condition was stabilizing, but despite his best efforts, the patient was unable to control his use or antisocial behaviors, with attendant probability of imminent danger, significant functional deficits or personality disorder symptoms, functional deficits of a pervasive nature, requiring treatment that is primarily habilitative in focus, or personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Thus, the patient did not meet the requirements for this dimension. For dimension 4, the patient was motivated for recovery. He presented for treatment voluntarily. He was engaged and actively participating in treatment. The patient found a sponsor and he reported that he was willing to actively involve his family in his treatment. Based on the clinical findings, the patient did not display a limited insight or awareness or difficulty understanding his substance use disorder. He was not opposed to addressing the severity of his substance use issues, and he was motivated to make positive changes. The patient was not in imminent danger of continued used because of the intensity of his addictive disorder or attributes his alcohol, drug, addictive, or mental health problem. Thus, the patient did not meet the requirements for this dimension. For dimension 5, the patient was working on relapse prevention skills and he secured a sponsor. He agreed with a plan for treatment with naltrexone. He also recognized that he was not ready to immediately return home due to stressors in his home environment. The patient did not meet subcriteria (a) through (f) as he was able to recognize relapse triggers, interrupt the relapse process, and did not require close 24-hour monitoring and structured support. The patient was not in imminent danger of relapse or demonstrating a need for 24-hour structure to help him apply recovery and coping skills. Thus, the patient did not meet the requirements for this dimension.For dimension 6, the patient was experiencing some issues within his family related to his substance use. While the patients father agreed to no longer use cannabis with the patient, he did not plan to alter his own use pattern. The patients mother also has a history of alcohol use issues, but she has maintained sobriety for an extended period of time. The patients parents were motivated to support him. The patient actively worked in family therapy to be open with his parents about things in the family environment that were stressful and a potential relapse trigger for him. He agreed with a recommendation to reside in a sober environment prior to transitioning home. The patients social network involves living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs. Given these findings, the patient did not meet all of the six ASAM dimensions required to support RTC services. Therefore, the RTC services 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.