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 (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 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 patient was treated for alcohol withdrawal with Librium earlier in his treatment stay. The patients withdrawal needs could have been safely managed in Level 3.1 setting. For dimension 2, the patient has asthma and scoliosis. The patients biomedical problems were stable and did not require medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with PTSD, anxiety, and depression. The patient was noted to have difficulty with interpersonal interactions and was described as somewhat paranoid. The provider noted that the patient was quick to anger when frustrated while in the treatment program. The patient endorsed use of alcohol and cannabis daily since adolescence. The patient lacks coping skills or knowledge of relapse triggers, although he did participate in groups. 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. In addition, the patient has a diagnosed emotional, behavioral, or cognitive disorder that required monitoring of medications or assessment of psychiatric symptoms or behavioral management techniques, because the history suggests that these disorders were likely to distract him from treatment efforts. For dimension 4, the patient admitted himself for treatment voluntarily due to problems being a responsible father to his daughter, relationship problems with his girlfriend, and inability to maintain employment due to his substance use disorder. The patient was able to acknowledge negative consequences of his substance usage. The patient acknowledges the existence of a substance use problem. He recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.  For dimension 5, the patient endorsed drinking one to two pints of vodka and smoking cannabis heavily on a daily basis for the past two years. The patients only period of sobriety was a 45-day period of recovery while in the residential setting. The patient has experienced multiple blackouts while using and he has a history of two suicide attempts in the past two years. He has history of relapse within hours of leaving residential facilities due to lack of coping skills. The patient demonstrated limited coping skills to address relapse triggers and urge. He thus was in imminent danger of relapse with dangerous behavioral consequences and needed 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient lives alone. The patients girlfriend and his daughter have been living apart from him due to his substance usage. The patients group of friends and former work associates use substances. He does not appear to have a sober social support network other than his girlfriend. The provider noted that the patient has limited knowledge of coping skills or relapse triggers. The patient has been able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities. The patients social network involves regular users of alcohol and/or other drugs, such that recovery goals were assessed as unachievable at a less intensive level of care. Based on these findings, the patient meets the six ASAM dimensions to support Level 3.1 RTC services. Therefore, the RTC services (ASAM 3.1) were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation 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.