Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 37-year-old male who was admitted to a residential treatment center (RTC) on 
3/1/22 and presented for a biopsychosocial assessment on 3/2/22. The patient has requested 
reimbursement for adult substance use disorder RTC from 3/1/22 through 4/4/22. The Health 
Insurer has denied this request and reported that the services at issue were not medically necessary 
for the treatment of this patient. This denial is the subject of this appeal and determination. 
The physician reviewer found that per American Society of Addiction Medicine (ASAM) criteria, 
this patient did not meet Level 3.2 criteria for RTC services from 3/1/22 through 4/4/22. 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  was  assessed  for 
amphetamine withdrawal and the records did not note any indications of alcohol withdrawal 
symptoms. The records did not note other substances other than amphetamine. The patients vital 
signs were within normal limits during his stay except for an elevated pulse of 110 beats per minute 
on 3/3/22. The patient was not in moderate-to-severe withdrawal. This criterion was not met. For 
dimension  2,  the  patient  did  not  have  medical  problems  that  would  complicate  potential 
withdrawal management. This criterion was not met. For dimension 3, the patient was diagnosed 
with unspecified anxiety disorder. He was not suicidal or homicidal and did not have a history of 
overdose, suicide attempts, or aggressive behaviors toward others. He did not have a diagnosis of 
severe or persistent mental illness or of cognitive disorder. This criterion was not met. For 
dimension 4, the patient admitted himself for treatment of prescription amphetamine use disorder. 
He was able to admit that he had difficulty with prescription Adderall and participated in his 
treatment. He expressed interest in changing due to the negative effects on his mental health and 
well-being. The records did not indicate that the patient had limited insight and little awareness of 
the  need  for  continuing  care,  marked  difficulty  in  understanding  the  relationship  between 
substance use, mental health, or life problems  and her impaired coping skills and level of 
functioning, demonstrated passive or active opposition to addressing the severity of his addiction 
problem, or required structured therapy and a 24 hour programmatic milieu because motivational 
interventions had not succeeded at less intensive levels of care. The patient did not have a 
perspective that impaired his ability to make behavior changes without repeated, structured 
motivational interventions, express little to no interest in changing, or attribute his alcohol, drug 
or mental health problem to other persons or external events. This criterion was not met. For 
dimension 5, the patient reported taking prescription Adderall at a dosage of 30 to 40 mg daily.  
He later reported drinking three to five bottles of sake regularly. The patient recognized the need 
for treatment and continuing care. The patient did not have a history of suicidal or homicidal 
ideation, suicide attempts or aggression. The records did not indicate that the patient lacked insight 
into benefits of continuing care and was therefore not committed to treatment, was unable to 
control use of alcohol or experiencing cravings with the situation posing an imminent danger of 
harm to self or others in the absence of close 24-hour monitoring and structured support, was in 
imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a 
result of a crisis situation, continued to use alcohol despite recent active participation in treatment 
at a less intensive level of care, or demonstrated a lifetime history of repeated incarceration. This  criterion was not met. For dimension 6, the patient lived with his parents, who appeared supportive 
of his treatment. Given these findings, the patient did not meet the six ASAM criteria for RTC 
services provided from 3/1/22 through 4/4/22. Accordingly, adult substance use disorder RTC 
from 3/1/22 through 4/4/22 was not medically necessary for treatment of this patient.