Appeal type: Medical Necessity
Decision: Overturned 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. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 was treated for withdrawal earlier in his RTC stay. The patients withdrawal needs were safely managed in level 3.1 setting. For dimension 2, the patient has hypertension. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring. For dimension 3, the patient has diagnoses of generalized anxiety disorder, obsessive compulsive disorder, posttraumatic stress disorder, and transvestic fetishism. He reported being increasingly depressed and anxious due to his familys reaction to his preference to dress as a woman, including his wife of 36 years wanting a divorce and his adult children being in various stages of acceptance or denial. He was using drinking and substances to cope with his anxiety and depression and has not yet developed the coping skills to manage rejection and ostracism from his family. He participated in group therapy. The patients mental status was stable enough to permit participation, and his anxiety, guilt, and depression may be related to substance use problems or to a stable co-occurring condition, with imminent likelihood of relapse with dangerous consequences outside of a structured environment.For dimension 4, the patient reported admitting himself to treatment voluntarily because he felt that his life was falling apart due to his drinking and substance use. He acknowledged negative consequences of his substance use, including relationship discord with his wife and adult children and a lack of sober friends. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery.For dimension 5, the patient has been drinking up to four liters of wine daily for the past three to five years, along with daily suboxone, Percocet, or cannabis use. He had a 100-day period of sobriety following a previous RTC stay, but subsequently relapsed with escalating usage that he attributed to the stress of disclosing his preference to dress as a woman to his family. He reported worsening depression and anxiety due to rejection from his family, an uncomfortable home situation, and lack of social supports. He lived in the family home with his wife, her boyfriend and an adult son who was using heroin. He reported that no one spoke to him at home and was unable to cope without drinking or using substances. Despite understanding his addiction and mental disorder, the patient is at risk of relapse in the absence of close 24-hour monitoring and structured treatment because he is consistently unable to address either or both.For dimension 6, the patient lives with his wife, her boyfriend, and an adult son who uses heroin in the home. He is socially isolated inside and outside of the home without social supports or network. The patients living environment makes recovery unlikely, and he has insufficient resources and skills to maintain an adequate level of functioning such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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 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.