Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 26-year-old female who presented for an admission assessment at a residential 
treatment center (RTC) on 12/31/22. The patient has requested reimbursement for residential 
substance abuse treatment at Harmony Place from 1/25/22 through 2/9/22. The physician reviewer 
found that per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 
3.5  criteria  for  RTC  services  from  1/25/22  through  2/9/22.  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 opioid and alcohol withdrawal 
earlier in her treatment stay. The patients withdrawal needs were safely managed in a Level 3.5 
setting.  
For dimension 2, the patient has fibromyalgia, lupus, and chronic pain. The patients biomedical 
problems were stable and did not require 24-hour medical or nurse monitoring.  
For dimension 3, the patient was diagnosed with PTSD, depression, and anxiety. She reported 
anxiety, intrusive memories of past trauma, and was noted by staff on multiple occasions to have 
difficulty  with  emotional  dysregulation.  The  records  noted  that  the  patient  had  been  using 
substances to manage difficult emotions since adolescence, drinking since age 15, escalating to 
Xanax by age 17 to escape painful thoughts, and further escalating to methamphetamine and heroin 
use. The records noted a history of blackouts and of being victimized during a blackout. The 
patients mental status was stable enough to permit participation. She demonstrated a repeated 
inability to control her impulses to use substances and was in imminent danger of relapse with 
attendant likelihood of harm to self, with a resulting level of dysfunction so severe that it precluded 
the patient's participation in a less structured treatment environment.  
For dimension 4, the patient was admitted voluntarily for treatment after relapsing following 
discharge from another treatment program. Although she requested treatment, she was often 
noncompliant with medication recommendations and was often late to groups. The records noted 
a review by administration due to the degree of the patients noncompliance with the program. She 
was assessed as having limited recognition of the severity of her addiction and not fully ready to 
give up her previous lifestyle. The records noted consistent substance use since age 15, which had 
affected the patients cognitive ability to regulate her emotions and tolerate distress. Due to the 
intensity  and  chronicity  of  the  addictive  disorder,  the  patient  had  limited  insight  and  little 
awareness of the need for continuing care or the existence of her substance use and need for 
treatment, and thus had limited readiness to change.  
For dimension 5, this was the patients fourth attempt at treatment. She reported using heroin and 
methamphetamine intravenously daily. She had relapsed immediately after discharge from a 
program in December, using substances until she was admitted to the RTC. She was unemployed 
due to her substance use. She had a troubled relationship with her family due to her substance use, 
had been kicked out of the home, and was living in her car. She was in an abusive relationship 
with the individual who introduced her to substances, remaining in contract with and failing to 
recognize this individual as a trigger for relapse. The patient did not recognize relapse triggers and 
had little awareness of the need for continuing care and was therefore not committed to treatment. 
Her continued substance use posed an imminent danger of harm to self or others in the absence of 
24-hour monitoring and structured support.   For dimension 6, the patient was homeless and living in her car after being kicked out of the family 
home. She was unemployed due to her substance use. She did not have a sober support system and 
had relapsed immediately after discharge from a prior program. She had an abusive ex-partner who 
used drugs that she remained in contact with. The patient was unable to cope, for even limited 
periods of time, outside of 24-hour care. She needed staff monitoring to learn to cope with 
problems before being transferred safely to a less intensive setting. 
Given these findings, the patient met the six ASAM criteria for RTC services provided from 
1/25/22 through 2/9/22. Accordingly, residential substance abuse treatment at Harmony Place from 
1/25/22 through 2/9/22 were medically necessary for treatment of this patient.