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 comprehensive addiction treatment services (ASAM Level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for residential treatment center (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. For dimension 1, the patient did not show evidence of significant alcohol withdrawal. Based on the available documentation, the patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient does not have significant medical problems. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient is noted as being diagnosed with depression and anxiety. She was not suicidal or homicidal. She does not have a history of overdose, suicide attempts, or aggressive behaviors toward others. The provider noted that the patient has participated in groups. Overall, the records document that the patients mental status has been 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 does not meet any of the other qualifying criteria including unable to control her use of alcohol and drugs with attendant probability of imminent danger or demonstrates repeated inability to control her impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. There is a lack of evidence that the patient demonstrates antisocial behavior patterns, or has significant functional deficits, which are likely to respond to staff interventions...of pervasive nature requiring treatment that is primarily habilitative in focus, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 4, the patient is able to admit that she has an alcohol use disorder, and she has participated in her treatment. The patient has expressed interest in changing. The records do not indicate that the patient demonstrates limited insight and little awareness of the need for continuing care, has marked difficulty in understanding the relationship between her substance use, mental health, or life problems and her impaired coping skills and level of functioning, or that she demonstrates passive or active opposition to addressing the severity of her addiction problem. There is a lack of evidence that the patient requires structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care, that her perspective impairs her ability to make behavior changes without repeated, structured motivational interventions, or expresses little to no interest in changing, or that the patient attributes her alcohol, drug or mental health problem to other persons or external events. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 5, the patient was drinking approximately 16 drinks per day over the last several months after a progressive increase in the amount and frequency of her alcohol usage over several years. The patient has recognized that she requires treatment and continuing care. She started naltrexone while in the facility. The patient has no history of suicide attempt, and she denies suicidal and homicidal ideation. The patient has no reported history of aggression. The records do not document that the patient lacks insight into benefits of continuing care and is therefore not committed to treatment, unable to control use of alcohol or drugs with attendant probability of harm to self or others, or experiencing craving...with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, or is in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation. There is a lack of report that despite recent active participation in treatment at a less intensive level of care, the patient continues to use alcohol or drugs, or demonstrates a lifetime history of repeated incarceration. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 6, the patient was living with her boyfriend who drinks and smokes cannabis daily. The patient was contemplating other living arrangements. There is adequate documentation that 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 does not meet Level 3.5 RTC criteria for dimensions 3, 4, or 5. The ASAM criteria require adult patients to meet all six dimensions to support Level 3.5 RTC services. Thus, the patient does not meet the ASAM requirements for Level 3.5 RTC services. Moreover, the Level 3.5 RTC services are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. All told, the residential comprehensive addiction treatment services (ASAM Level 3.5) were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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.