Appeal type: Medical Necessity
Decision: Overturned 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 meets 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 can be met in Level 3.5 setting. Recently, the patient still had mild to moderate withdrawal symptoms of agitation, anxiety, and diaphoresis. He has been monitored and treated for withdrawal. For dimension 2, the patient has diabetes, obstructive sleep apnea, ulcerative colitis, and hypertension. 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 has diagnoses of post-traumatic stress disorder (PTSD) and bipolar depression. The records document that he has attempted suicide eight times within the past six months. He is having difficulty processing his divorce and has been drinking uncontrollably in response. The provider noted that the patient has significant underlying anger and aggressiveness, which he has used alcohol to manage. The patients mental status is 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. The patient has significant functional deficits which are likely to respond to staff interventions. These symptoms are sufficiently severe that the patient is not likely to maintain abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus, and include residual psychiatric symptoms and inadequate anger management skills. For dimension 4, the patient agreed to admission after being found on the streets binge drinking vodka. The patient endorses drinking one-fifth of vodka daily for five years. He recently chose to continue drinking and live homeless in response to his wife divorcing him. The patients perspective impairs his ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable him to develop insight into the role he plays in his substance use and mental condition and empower him to make behavioral changes which can only be delivered in a 24-hour milieu. For dimension 5, the patient has been drinking on a daily basis since age 17, and he reports that his longest period of sobriety was six months. He was treated in an RTC program earlier in 2020. He has not been able to identify relapse triggers other than boredom. He also has significant anxiety and trauma that are believed to affect his ability to remain sober. He has attempted suicide eight times in the past six months. 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 patient has been living on the streets rather than remaining sober in housing. He is socially isolated due to his divorce and his social network is composed of other drinkers. The patients social network is characterized by significant social isolation or withdrawal, such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services were and are 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.