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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) (ASAM 3.5) services. Findings:  The physician reviewer found that he American Society of Addiction Medicine (ASAM) criteria, this patient met 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 with valium throughout his treatment stay. The patients withdrawal needs could have been safely managed in a Level 3.5 setting.For dimension 2, the patient presented to the RTC as mildly to moderately intoxicated. The provider noted the presence of tremors and mild distress. The records document that the patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with anxiety disorder. He has been drinking 1.5 pints of vodka daily for the past six months. He was at a detox within the two months of this admission and drank after he returned home. He reports drinking to cope with his depression and anxiety. The patients mental status was 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. In addition, the patient demonstrated 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 to RTC for treatment after relapsing six months ago and drinking 1.5 pints of vodka daily. Previous treatment has included detoxification services, which was followed by relapse after he returned home. The patient endorsed drinking to manage anxiety and depression. The provider noted that the patient lacks insight into coping with these feelings without using alcohol. He has been drinking problematically for many years and has had escalation of his alcohol use since the pandemic. He has developed a high tolerance as evidenced by his elevated blood alcohol level on admission. He blamed relapse on learning bad news about a relative. The records support that despite experiencing serious consequences or effects of the addictive disorder, the patient has marked difficulty in understanding the relationship between his substance use, addiction, mental health or life problems and his impaired coping skills and level of functioning, often blaming others for his addiction problems. For dimension 5, the patient was managed for withdrawal with a seven-day valium taper. The provider noted that the patient was open to resuming naltrexone and starting vivitrol injection as part of his discharge plan. The patient was experiencing addiction symptoms such as drug craving. This situation posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support was 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 has not been able to cope without using alcohol outside of detoxification except for a two-month period. The patient endorsed drinking throughout the day and hiding it from his spouse. The patient was in a relapse for months drinking heavily in his home environment and he was unable to cope with managing his anxiety without the use of alcohol. The patient was unable to cope, for even limited periods of time, outside of 24-hour care. He needed 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 ASAM criteria for RTC Level 3.5 services. Moreover, the RTC services were 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 (ASAM 3.5) services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.