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

An enrollee has requested reimbursement and authorization and coverage for Residential Treatment Center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.5 criteria for residential treatment center services. ASAM criteria focus on six dimensions to determine the appropriate level of care. For dimension 1, detoxification/withdrawal potential, the patient still had mild to moderate withdrawal symptoms of agitation, anxiety, headache and tremors. He was managed for withdrawal with a Librium taper, and his withdrawal needs were safely managed in the residential treatment center setting. For dimension 2, biomedical conditions and complications, the patient had been recently hospitalized for alcohol-induced pancreatitis, he was also status post left sided cerebral infarction, and he had a history of stage IV tongue cancer. With continued drinking he would have been at risk for another episode of pancreatitis. The patients medical status was stable upon admission to the residential treatment center, however, and his biomedical condition was not severe enough to warrant inpatient treatment. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patient had a history of major depressive disorder and anxiety. He admitted that he used alcohol to manage his anxiety. He was also noted to have cognitive deficits upon evaluation, but he was able to participate in groups. The patient was also noted to have a history of anger, outbursts and rage. He has noted to have previously left treatment facilities impulsively and started drinking again. He also spent six hours getting to the facility because he kept stopping to drink alcohol, despite having previous DUI's. The patients mental status permits participation. In addition, the patient had a repeated inability to control his impulses to use alcohol, and he was in imminent danger of relapse with likelihood of harm to others. For dimension 4, readiness to change, the patient had been to several residential treatment centers over the past year. The patient agreed to enter treatment this time after being hospitalized for pancreatitis due to his alcohol use, but he drove while intoxicated to the facility. The patients current marriage is ending due to his alcohol usage. In this case, because of the intensity and chronicity of the patients addictive disorder, he has limited insight and little awareness of the need for continuing care. For dimension 5, relapse, continued use, or continued problem potential, the patient has had multiple relapses since the onset of very heavy drinking three years ago. He has been using alcohol as a way to manage his anxiety. He acknowledged ongoing cravings to use alcohol with his reported level of craving being an 8 out of 10. The patient is currently prescribed naltrexone orally to assist with reducing cravings. The patient is therefore experiencing addiction symptoms such as cravings, and this situation poses an imminent risk of harm to self or others in the absence of close 24-hour monitoring and structured support. For dimension 6, recovery/living environment, the patient lives with his soon to be ex-wife as they are planning on divorce. He does not have a sober support system, and he has been unable to refrain from alcohol use in the absence of a structured setting for the past three years. The patient has been unable to cope outside of 24-hour care, and he needs staff monitoring to learn to cope with his recovery environment problems before being transferred safely to a less intensive setting. Using the ASAM level 3.5 criteria worksheet, the patient meets all six criteria for medical necessity and therefore qualifies for ASAM Level 3.5 treatment. Accordingly, the Residential Treatment Center (RTC) services in issue and requested services were, and are, medically necessary for the patients medical condition.