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 (ASAM level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet 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 patient was treated for alcohol withdrawal with 10-day valium taper earlier in his stay. The patients withdrawal needs could have been safely managed in a Level 3.5 setting.For dimension 2, the patient has a history of hypertension. The patients biomedical problems, if any, 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 reported depressive and anxiety symptoms. He was not suicidal or homicidal. The patient reported marital discord as well as some conflicts with others on occasion. The provider notes that the patient was able to follow the rules of the facility and there were no noted functional deficits. The patient participated in groups. 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 does not meet any of the other qualifying criteria for this dimension, including unable to control his use of alcohol and drugs with attendant probability of imminent danger, demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, has significant functional deficits, or a severe concomitant personality disorder. Based on these findings, the patient did not meet the requirements for this dimension. For dimension 4, the patient voluntarily admitted himself for treatment since he was unable to control his lifestyle of daily drinking and binge cocaine usage. The patient actively participated in treatment and had good insight into his addictions. The patient did not meet the requirements for this dimension, including limited insight and little awareness of the need for continuing care, demonstrated passive or active opposition to addressing the severity of his addiction problem, required structured therapy and a 24 hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care, or perspective impaired his ability to make behavior changes without repeated, structured motivational interventions. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 5, the patient was drinking 10 to 12 shots of alcohol daily and using cocaine in a binge type manner. This was his first attempt at treatment. The patient denied suicidal and homicidal ideation. There is no reported history of suicide attempt or aggressive behaviors. The patient did not meet the requirements for this dimension, including lacked insight into benefits of continuing care, unable to control use of alcohol or drugs with attendant probability of harm to self or others, experiencing craving...with the situation posing an imminent danger of harm to self or others, in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, or despite recent active participation in treatment at a less intensive level of care, the patient continued to use alcohol or drugs. Based on these findings, the patient did not meet the requirements for this dimension.For dimension 6, the patient is married and was recently evicted from his home due to his substance usage and marital discord. The patient declined to go to a sober living environment. The patient did not meet the requirements for this dimension including living in an environment that is characterized by a moderately high risk of neglect, substance abuse so endemic that the patient was assessed as being unable to achieve or maintain recovery at a less intensive level of care, social network of regular users of drugs, living with an individual who is a regular user or dealer of other drugs, or inability to cope for even limited periods of time, outside of 24-hour care. Based on these findings, the patient did not meet the requirements for this dimension. The ASAM criteria requires adult patients to meet all six dimensions to support RTC services. This patient did not meet Level 3.5 RTC criteria for dimensions 3, 4, 5 and 6. Moreover, the services were 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. Given these findings, the RTC services (ASAM level 3.5) 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.