Appeal type: Medical Necessity
Decision: Upheld 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. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does 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 earlier in his course of treatment. Based on the records, the patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient has short-term memory impairment due to a traumatic brain injury in 2004. The records document that the patients biomedical problems are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with ADHD, PTSD, and GAD as well as mild neurocognitive disorder due to a traumatic brain injury. There is mention of report of possible domestic violence. The provider noted that the patient has participated in groups. The patients mental status has been assessed as sufficiently stable to permit participation. However, the patient does not meet any of the other qualifying criteria 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, with attendant likelihood of harm to self, others, or property, or demonstrates antisocial behavior patterns. The records do not support that the patient has significant functional deficits, which are likely to respond to staff interventions...of pervasive nature requiring treatment that is primarily habilitative in focus, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 4, the patient voluntarily admitted himself for treatment to seek help for drinking and using substances to manage his problems and stress. The patient has been able to admit that he has alcohol use disorder, and he has participated in his treatment. The patient has expressed interest in changing due to negative effects on his marriage. However, there is a lack of documentation to support that the patient requires 24-hour programmatic milieu to sustain motivation. The patient does not have limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between his substance use, mental health, or life problems and his impaired coping skills and level of functioning, often blaming others for his addiction problems. The records do not support that the patient demonstrates passive or active opposition to addressing the severity of his addiction problem, that he requires structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care, or that his perspective impairs his ability to make behavior changes without repeated, structured motivational interventions. The patient has expressed interest in changing, and does not attributes his alcohol, drug or mental health problem to other persons or external events. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 5, the patient endorsed drinking one-fifth of liquor daily in addition to Xanax and stimulants since he relapsed. The patient recognizes the need for treatment and continuing care. He has no suicidal ideation or homicidal ideation. There are no reported issues of imminent danger of harm to self or others. Given these findings, the patient does not lack insight into benefits of continuing care. The patient has not been unable to control use of alcohol or drugs with attendant probability of harm to self or others or experiencing craving...with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. There is a lack of evidence that the patient is in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, that the patient continues to use alcohol or drugs, or demonstrates a lifetime history of repeated incarceration. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 6, the patient is living with his wife and children. He reports that his wife is also being treated with stimulants for ADHD, which may represent a problem. The patient regularly attends Alcoholics Anonymous (AA) meetings. The patients social network involves living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs. The ASAM criteria require adult patients to meet all six dimensions to support an indication for Level 3.5 services. Based on the available documentation, this patient does not meet ASAM Level 3.5 RTC requirements for dimensions 3, 4, and 5. Moreover, ASAM Level 3.5 RTC services were not and are 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. For these reasons, the RTC services (ASAM level 3.5) were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are 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.