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 (ASAM Level 3.2 and Level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.2 criteria for clinically managed RTC withdrawal management services, and 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 underwent withdrawal management for alcohol withdrawal earlier in his treatment stay. The patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient has leukemia and several other chronic medical problems. 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 been diagnosed with anxiety and depressive disorder. He also has significant medical problems including leukemia and history of alcoholic pancreatitis that required hospital admission. The patient was drinking so heavily that he missed important tests for his leukemia treatment including bone marrow biopsy, which represents a likelihood of ongoing harm to himself. 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 has demonstrated a repeated inability to control his impulses to use alcohol and other drugs or to engage in antisocial behavior and is in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was voluntarily admitted for treatment after being unable to stop drinking on his own. The patient endorsed drinking 1.75 gallons of vodka daily for most of the past 15 years. The patient has been in a relapse for the past eight months after his wife divorced him due to his alcohol use. The patient has been unable to sustain behavioral changes in the community and he has experienced multiple relapses despite consequences of divorce and the development of significant medical problems over the past year. The records support that 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 empower him to make behavioral changes which can only be delivered in a 24-hour milieu. For dimension 5, this patient was started on naltrexone and Vivitrol injection as part of his treatment. Previously, the patient did not follow through with receiving this treatment regimen in the outpatient setting. He was also drinking to the point of blackouts and he was neglecting work-up of his leukemia due to his inability to stop drinking. The patient is experiencing addiction symptoms such as drug craving. This situation poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors. For dimension 6, the patient lives alone after his wife divorced him due to his ongoing drinking. He does not have a relationship with his adult children due to his drinking. He does not have a support system. He has been in a relapse for months in home environment despite significant medical comorbidities. There is documentation that the patient has been unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for the RTC services provided from 8/20/21 forward. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the RTC services (ASAM 3.2) and RTC services (ASAM 3.5) 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.