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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet the criteria for RTC services (ASAM 3.5). 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 treated for alcohol withdrawal earlier in her course of treatment. Based on clinical findings, the patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient has diabetes, hypertension, Hashimotos thyroiditis, and chronic pain. Per the records, the patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring.For dimension 3, the patient has a history of depression and anxiety. She was not suicidal or homicidal. The records noted a history of overdose in her early 20s, but she denied current suicidality. She does not have aggressive behaviors toward others. She participated in groups. Although the patients mental status is stable to permit participation, she does not meet any of the other qualifying criteria for this dimension. The records do not document that the patient is unable to control her use of alcohol and drugs with attendant probability of imminent danger within hours or days. The records do not document that the patient demonstrates repeated inability to control her impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property. This patient has a history of DUI with a suspended license. There was no indication the patient continued to drive without a license, and thus, there is no indication the patients condition constitutes further imminent threat to others. The clinical notes do not indicate that the patient demonstrates antisocial behavior patterns. The records do not document that the patient has significant functional deficits, which are likely to respond to staff interventions...of pervasive nature requiring treatment that is primarily habilitative in focus; they do not require medical monitoring and management. The records do not indicate concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. This criteria is not met. For dimension 4, the patient admitted herself for treatment voluntarily after relapsing several weeks after discharge from the same facility. She participated in her treatment. There is no documentation to support that she requires 24-hour programmatic milieu to sustain motivation. The patient does not meet the sub-criteria of limited insight and little awareness of the need for continuing care. The records do not document that the patient has marked difficulty in understanding the relationship between her substance use, mental health, or life problems and her impaired coping skills and level of functioning. The documentation does not demonstrate passive or active opposition to addressing the severity of her addiction problem. The records do not indicate that the patient requires structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care. The documentation does not demonstrate that the patients perspective impairs her ability to make behavior changes without repeated, structured motivational interventions. The patient does not attribute her alcohol, drug or mental health problem to other persons or external events. This criteria is not met.For dimension 5, the patient was drinking two to six beers daily since she relapsed two weeks prior to admission. She recognized the need for treatment and continuing care. She had no suicidal ideation or homicidal ideation. She has not been suicidal and has not been noted to be an imminent danger to others. The records do not indicate that the patient lacks insights into benefits of continuing care and is therefore not committed to treatment. The records do not indicate that the patient is experiencing craving...with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. The documentation does not indicate that the patient is in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation. The documentation does not show that despite recent active participation in treatment at a less intensive level of care, the patient continues to use alcohol or drugs, or that the patient demonstrates a lifetime history of repeated incarceration. Therefore, this criteria is not met. For dimension 6, the patient lives with her sister who is sober and is in a supportive sober living environment.  She is retired. She has a difficult relationship with her son, which is stressful and a relapse trigger for her. The patient does not meet criteria of living in an environment that is characterized by a moderately high risk of neglect...physical, sexual, or emotional abuse, or substance use so endemic that the patient is assessed as being unable to achieve or maintain recovery at a less intensive level of care. The records do not show that the patients social network includes regular users of alcohol such that recovery goals are assessed as unachievable at a less intensive level of care. The documentation does not demonstrate that the patients social network is characterized by significant social isolation or withdrawal such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. The records do not show that the patients social network involves living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs. The documentation does not demonstrate that the patient is unable to cope, for even limited periods of time, outside of 24-hour care. Therefore, this criteria is not met. Thus, this patient does not meet Level 3.5 RTC criteria for dimensions 3, 4, 5 or 6. The services at issue were not and are not in accordance with the generally accepted standards of mental health and substance use disorder care. The services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. Therefore, RTC services (ASAM 3.5) at The Lakes Treatment Center provided from were not and are not medically necessary for the treatment of this patient.