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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Residential Treatment Center level of care. Findings:  The physician reviewer found that Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.1 criteria for Residential Treatment Center (RTC) services. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient has no current acute intoxication or withdrawal issues. Based on clinical findings, the patients withdrawal needs can be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that patient has chronic pain that is controlled on tramadol. The patients biomedical problems are therefore stable and do not require medical or nurse monitoring.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient was diagnosed with major depressive disorder, recurrent, panic disorder, and generalized anxiety disorder. She has been complaining of significant anxiety and panic that lead to urges to drink alcohol. She has low appetite with weight loss. She has significant symptoms related to her history of neglect and abuse from her family of origin. She has been using alcohol to cope with this stress. Records reflect that the patient has actively participated in groups. The patients mental status is sufficiently stable to permit participation in the therapies provided in the residential treatment center, and her symptoms and functional limitations (residual psychiatric symptoms and chronic addictive disorder) are sufficiently severe that she is not likely to maintain abstinence if treatment is provided in a nonresidential setting.For dimension 4 - Readiness to Change. The patient admitted herself to residential treatment center care voluntarily after having two months of continuous binge drinking such that she lost her job and is homeless. She was discharged from the residential treatment center facility and has been at a sober living environment, but she reports struggling there with urges to drink due to severe anxiety. She reportedly made progress in treatment in the residential treatment center but is having difficulty coping at the lower level of care. Her psychiatrist reports that outpatient motivational treatments have previously failed in the outpatient setting. The patient requires a 24-hour structured milieu to promote treatment progress and recovery, because motivating interventions have failed in the past and such interventions are not likely to succeed in an outpatient setting.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient has been drinking very heavily on a daily basis, with her longest period of sobriety being three weeks. She has had several attempts to quit with very little improvement. She uses alcohol in a maladaptive manner in order to cope with anxiety and a history of trauma. She has been unable to manage more than three weeks of sobriety in an unstructured setting. She has requested a higher level of care due to urges to drink and difficulty managing psychiatric symptoms without resorting to alcohol usage. The patient has demonstrated limited coping skills to address her relapse triggers and urges, and she is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills.For dimension 6 - Recovery Environment. The patient was homeless but has been staying at a sober living environment. She is socially isolated. She is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. The patient also lacks social contacts, leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting.Using the ASAM level 3.1 criteria worksheet, the patient meets all six criteria for medical necessity and therefore qualifies for ASAM Level 3.1 treatment. Accordingly, the requested Residential Treatment Center level of care is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's medical condition. Therefore, the Health Plans denial should be overturned.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.