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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.1 or 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 admitted to RTC and managed for withdrawal with Neurontin. Based on the clinical findings, the patients withdrawal needs could have been met in a Level 3.1 setting. For dimension 2, the patient has hypertension, elevated liver function test results, and he was diagnosed with cellulitis while at the RTC. The patients biomedical problems, if any, were stable and did not require medical or nurse monitoring. For dimension 3, the patient was diagnosed with major depressive disorder, severe, recurrent and he has been treated with Lexapro. His depression and anxiety were partially improved by discharge. He was not suicidal or homicidal, and his ability to perform activities of daily living had improved. He participated in groups. 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. The patient had significant functional deficits, which were likely to respond to staff interventions. These symptoms and deficits, when considered in the context of his home environment, were not sufficiently severe that he was assessed as not likely to maintain mental stability and abstinence if treatment was provided in a nonresidential setting. Based on the available documentation, the patient did not meet this requirement. For dimension 4, the patient admitted himself for treatment of his alcohol use disorder as his partner gave him an ultimatum. He was unable to stop drinking on his own for longer than two weeks. He expressed a desire to become abstinent and he was able to identify negative consequences of  alcohol usage including occupational problems and relationship problems. The patient recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For , the patient endorsed drinking two pints on a daily basis for the past two years. This was his first attempt at treatment although he has tried to stop on his own previously. He had insight into relapse triggers and developing coping skills. The patient does not meet any of the criteria including imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences, understands addiction and mental disorder but was at risk of relapse in a less structured level of care, or needed staff support to maintain engagement in his recovery program while transitioning to life in the community. Based on the available documentation, the patient did not meet this requirement. For dimension 6, the patient lives with a roommate and his partner. The patients partner moved into a hotel until the patient had established sobriety. He is employed and he has a social support network and family support. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. However, the patient does not meet any of the other criteria since he was not living in an environment that is characterized by repetition of physical or emotional abuse, significant social isolation and withdrawal, or highly invested in alcohol. The patient was not shown to have insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Based on the available documentation, the patient did not meet this requirement. The ASAM criteria requires that adult patients meet all six dimensions for Level 3.1 or Level 3.5 RTC services. This patient does not meet criteria for dimensions 3, 5, or 6. Given these findings, the RTC services 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 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.