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. For dimension 1, the patients withdrawal needs were safely managed in a Level 3.5 setting. As of 5/15/20, the patient still had mild to moderate withdrawal symptoms of anxiety and tremors. She has a history of severe alcohol use, cirrhosis, and benzodiazepine use disorder. She was managed for withdrawal with a Librium taper. For dimension 2, the patients current biomedical condition is not severe enough to warrant inpatient treatment but is enough to distract from treatment or recovery efforts. The problem requires medical monitoring, which can be provided by the program. The patient required hospitalization for complications related to severe alcohol use disorder including cirrhosis, hepatitis encephalopathy, and esophageal varices. She then was admitted to the medical hospital due to noncompliance with her lactulose and then discharged back to the RTC the following day. With continued drinking she would be at risk for multiple complications of cirrhosis. Her medical status was stable upon readmission to the RTC. For dimension 3, the patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has diagnoses of bipolar I disorder and PTSD. She has reportedly experienced manic episodes in which she travels by herself to hotels and drinks heavily without her husband knowing her whereabouts. She was also noted to have cognitive slowing upon evaluation but was able to participate in the groups. She has continued to drink two bottles of wine daily for eight years despite worsening of medical problems. She has cirrhosis with esophageal varices and history of hepatic encephalopathy. She has severe impulsivity and need for immediate gratification as evidenced by refusal to take lactulose and to comply with low sodium diet. She has previously started drinking within hours of discharge from treatment. She demonstrated a repeated inability to control impulses to use alcohol and was in imminent danger of relapse with likelihood of harm to self. For dimension 4, the patient agreed to an admission after being told by her provider that continued drinking would jeopardize her life. She has been drinking heavily for 20 years, and at this level for the past eight years. The provider noted that the patient had great difficulty developing a plan to deal with her personal and external stressors. The patient reportedly relies on her husband and her marriage is strained due to her alcohol use disorder. The patient ultimately left against medical advice. Because of the intensity and chronicity of the addictive disorder, she has limited insight and little awareness of the need for continuing care or the existence of her substance use and the need for treatment, and thus had limited readiness to change. For dimension 5, the patient did not recognize relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment and poses an imminent risk of harm to self or others in the absence of close 24-hour monitoring and structured support. The patient has been in a relapse for the past eight years with only brief periods of sobriety since onset of heavy drinking 20 years ago. She relapsed within one day of discharge after her last RTC stay. She has severe medical problems related to her alcohol use disorder. The providers described the patient to be highly impulsive and focused on getting her way even if it was to her own detriment She ultimately elected to leave against medical advice. For dimension 6, the patient has been unable to cope, even for limited periods of time, outside of 24-hour care. The patient needed staff monitoring to learn to cope with dimension 6 problems. The patient lives with her husband but he is considering divorce. She does not have a sober support system. She has been unable to refrain from alcohol use in the absence of a structured setting and she has not been able to work in eight years. 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.