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 3.5 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. The patient has signs and symptoms of protracted withdrawal. The patients withdrawal can be safely managed at this level of care. The patient continues to have symptoms including anxiety, paroxysmal sweats, and tremor. The patient reports obsessive ruminations, severe anxiety with shortness of breath, and anhedonia. The patient requires staff attention for monitoring and adherence to medications. The patient was started on naltrexone, an anti-craving medication, in addition to his Acamprosate. The patients mental status is sufficient to permit participation. He has a history of attention-deficit/hyperactivity disorder (ADHD) and associated struggles with inattention, task completion, distractibility, and boredom. In addition, his severe anxiety and ruminations are also distractors to medication adherence without the staff support and level of care available in a 24-hour facility. The patient has demonstrated a repeated inability to control his impulses due to alcohol and he remains at imminent danger of harm to himself and others if he relapses. In addition, his anger management problems and protracted withdrawal symptoms require active monitoring. The records indicate that the intensity and chronicity of the patients alcohol use disorder have culminated in risky sexual relationships, legal issues, and aggressive outbursts. The patient has exhibited antisocial behavior that could lead to criminal justice issues. The patients history of ADHD require the structured therapy and 24-hour programmatic milieu to promote treatment progress and recovery as he has failed lower levels of care in the past. The patient has been unable to postpone the immediate gratification of using alcohol in a lower level of care that does not provide 24-hour monitoring and structured support. He has a history of aggressive behavior at home and continued low frustration tolerance. The patients recovery environment is not supportive of good mental health functioning as evidenced by his chaotic relationship with his father, who reportedly has a substance use disorder. He requires the support and structure of a Level 3.5 co-occurring enhanced program to achieve stabilization and prevent further deterioration and adverse consequences. Based on these findings, the patient meets the six dimensions of the ASAM framework for treatment at the RTC level of care. Accordingly, the RTC level of care 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 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.