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. Findings:  The physician reviewer found that Per the American Society of Addiction Medicine (ASAM) criteria this patient meets Level 3.5 criteria for RTC services provided from 11/18/20 forward. 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 last drink was in November 2020, and he was treated with a benzodiazepine taper. He had withdrawal symptoms of agitation, tremors, and anxiety. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient had COVID-19 during his treatment stay but was medically stable during his admission. 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 history of traumatic events related to his alcohol and drug usage including being held at gunpoint and being stabbed. He reports having tried to quit drinking on his own multiple times without any success. He recently went into the wilderness under the influence and became trapped in a ravine for five days, which led him to attempt suicide. He reports urges to use while in the facility. He is currently homeless and has no sober support system, which places him at high risk for relapse. 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. The patient demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient admitted himself voluntarily after his parents kicked him out of their house for using methamphetamine. He reported that he has tried to stop on his own, but this is his first treatment. Due to his alcohol and methamphetamine use, he is homeless, unemployed, and going through a divorce. He has been drinking a pint of liquor with a 12-pack of beer daily as well as intravenous methamphetamine every week for the past 15 years. Because of the intensity and chronicity of the addictive disorder and the patients mental health problems, he has limited insight and little awareness of the need for continuing care and thus has limited readiness to change. For dimension 5, the patient has not had any period of sobriety in the past 15 years. Prior treatment has not included RTC level of care. The patient was noted to blame his substance usage on his childhood and upbringing. He endorsed craving of 8/10 while in facility. He is currently homeless, unemployed, and he does not have sober support system. When using he puts himself in risky situations and has disappeared for days at a time, including getting trapped in the wilderness for five days. The patients psychiatric condition is stabilizing. However, despite his best efforts, the patient is unable to control his use of alcohol, other drugs with attendant probability of harm to self or others. The patient has limited ability to interrupt the relapse process or to use peer supports when at risk for relapse to his addiction. His continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient is homeless and unemployed. His social network consists of other drinkers and drug users. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as unachievable at a less intensive level of care. These findings demonstrate that the patient meets the six ASAM dimensions for RTC services. Therefore, the  dual diagnosis RTC services provided 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.