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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for subacute residential treatment center (RTC) level of care services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 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 had symptoms of withdrawal including anxiety, irritability, and agitation. He completed a benzodiazepine taper. The patients withdrawal needs were safely managed in a Level 3.1 setting. For dimension 2, continued alcohol usage placed this patients at health risk. He had elevated transaminases, and he has a diagnosis of testicular cancer and is status post orchiectomy. The patients biomedical problems were stable and did not require medical or nurse monitoring. For dimension 3, the patient has diagnoses of MDD, GAD, and PTSD. He reported significant anxiety about returning to home due to the conflict and stressors. His anxiety was associated with urges to use alcohol. The patient demonstrated through generalized anxiety, an inability to maintain stable behavior over a 24-hour period without the structure and support of a 24-hour setting. For dimension 4, the patient voluntarily admitted himself to the RTC due to the severity of his alcohol use as he was drinking all day during work and well into the night. He was motivated to complete the program. The patient acknowledged the existence of a substance use problem. He 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 dimension 5, the patient has a severe alcohol use disorder with a high consumption of alcohol on a daily basis. He went through alcohol withdrawal and experienced significant symptoms. He was noted to be impulsive and use alcohol in a maladaptive manner in order to cope with the stressors in his life. The patient was at high risk of substance use with dangerous emotional, behavioral, or cognitive consequences in the absence of close 24-hour structured support. For dimension 6, the patient lives with his partner and two young children. His partner is contemplating a change in gender from female to male and this has placed enormous stress and conflict between them. He was anxious about his return home due to these conflicts. His social contacts are substance users. 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. The patients social network includes friends who are regular users of alcohol leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the subacute RTC level of care services were medically necessary 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.