Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for RTC with 24-hour nursing services (ASAM Level 3.7) provided at New Dawn Recovery Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.7 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. Admission at ASAM Level 3.7 is appropriate when at least two of the six dimensions are met, at least one of which is dimension (1), (2), or (3). For dimension 1, the patients last drink was the week prior, and she did not require withdrawal management. The patient did not have severe withdrawal that required 24-hour nursing care. This criterion was not met.For dimension 2, the patient was hospitalized for pancreatitis but was medically stable at the time of her RTC admission. The records did not document recent symptomatology, and the patient was medically stable at the time of admission. The patients biomedical problems and alcohol use did not place her at significant risk of serious damage to physical health, and she did not have biomedical conditions requiring 24-hour nursing and medical monitoring or active treatment. This criterion was not met.For dimension 3, the patient was not suicidal, homicidal, or psychotic, and the records did not  suggest that she posed a risk of harm to herself or others if not contained in a 24-hour structured environment. This criterion was not met. For dimension 4, the patient was admitted voluntarily for treatment. She had left an IOP program after three months due to an assault and had relapsed. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery because motivational interventions have not succeeded at less intensive levels of care. She was noted to have limited insight into her addictive illness. She did not require intensive motivating strategies only available in a 24-hour structured and medically monitored setting, or ongoing 24-hour psychiatric monitoring to assure follow through with the treatment regimen. This criterion was not met. For dimension 5, the patient was unsuccessful at the IOP level of care, relapsing into using alcohol despite a recent diagnosis of pancreatitis and strained relationships with her husband and children. While she reported an intensification of her substance use disorder, she did not pose a serious risk of harm to self or others in the absence of 24-hour monitoring and structures support found in a medically monitored setting. This criterion was not met. For dimension 6, the patient was married with young children but reported significant marital problems and an inability to function as a parent due to her drinking. The patient had relapsed despite being in an IOP for three months prior to her RTC admission. The patient was unable to cope, for even limited periods of time, outside of 24-hour care, and required staff monitoring to learn to cope before being transferred safely to a less intensive setting.Given these findings, the patient did not meet the six ASAM Level 3.7 criteria for RTC services. In this patients case, RTC ASAM Level 3.7 level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, RTC with 24-hour nursing services (ASAM Level 3.7) at New Dawn Recovery Center 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 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.