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 provided by Living at Reflections. Per 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 underwent withdrawal management earlier in her RTC stay. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had multiple sclerosis with ongoing symptoms, including fatigue. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported symptoms of anxiety. She was not suicidal, homicidal, or psychotic, and the records did not note functional defects. The patient participated in group sessions. While the patients mental status was stable enough to permit participation, the records did not indicate that the patient was unable to control her use of alcohol and drugs with attendant probability of imminent danger, demonstrated repeated inability to control her impulses to use alcohol and other drugs and in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrated antisocial behavior patterns, had significant functional deficits of pervasive nature requiring treatment that was primarily habilitative in focus and likely to respond to staff intervention, or had concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provided opportunities to promote continuous boundary setting interventions. This criterion was not met.For dimension 4, the patient admitted herself for treatment voluntarily due to the effects of alcohol use on her health and relationships and participated in treatment. The records did not indicate that the patient had limited insight and little awareness of the need for continuing care; marked difficulty in understanding the relationship between her substance use, mental health, or life problems and her impaired coping skills and level of functioning; demonstrated passive or active opposition to addressing the severity of her addiction problem; required structured therapy and a 24-hour programmatic milieu because motivational interventions had not succeeded at less intensive levels of care; endorsed a perspective that impaired her ability to make behavior changes without repeated, structured motivational interventions; expressed little to no interest in changing, or attributed her alcohol, drug or mental health problem to other persons or external events. This criterion is not met.  For dimension 5, the patient reported drinking a bottle of wine daily for the past two years. She had insight into her alcohol use disorder and her need for treatment. She was treated for alcohol cravings with naltrexone. The records did not note suicidal or homicidal ideation, and there were no issues of probability of harm to self or others. The records did not indicate that the patient lacked insight into the benefits of continuing care and was therefore not committed to treatment; was unable to control use of alcohol or drugs with attendant probability of harm to self or others; was experiencing cravings with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support; was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation; continued to use alcohol or drugs despite recent active participation in treatment at a less intensive level of care; that the patient continues to use alcohol or drugs, or demonstrated a lifetime history of repeated incarceration. This criterion was not met. For dimension 6, the patient lived with her husband and children in a newly sober household as the husband reportedly stopped his own alcohol usage. She had family support. She developed support with Alcoholics Anonymous prior to her RTC discharge. She had previously maintained sobriety on her own during her pregnancies. The records did not indicate that the patient lived in an environment characterized by a moderately high risk of neglect, abuse or substance use so endemic that the patient was assessed as being unable to achieve or maintain recovery at a less intensive level of care, had a social network including regular users of alcohol or drugs, addicted user, or dealer of alcohol or other drugs or had a social network characterized by significant social isolation and withdrawal such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care, or that the patient was unable to cope, for even limited periods of time outside of 24-hour care. This criterion is not met.Given these findings, the patient did not meet the six ASAM criteria for RTC services. Accordingly, the RTC services provided by Living at Reflections 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.