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. For dimension 1, the patient endorsed drinking five shots of vodka daily for the past two months after an unclear period of sobriety. He was managed with a Librium taper but continued to complain of withdrawal symptoms including anxiety, agitation, and tremors. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient does not have any medical problems. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with PTSD and bipolar disorder, most recent episode manic. He has been using alcohol to manage his PTSD symptoms and to control his anxiety. He reports that he is unemployed due to his alcohol usage. He has been unable to live independently and resides with his parents. He was noted to have tremendous difficulty with managing impulsivity. The patient has experienced episodes of anger dyscontrol, and during one episode he punched out a window at the RTC. He was not able to socialize with his peers due to his suspiciousness of others. The patients mental status is assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has significant functional deficits which are likely to respond to staff interventions. These symptoms and deficits, when considered in the context of his home environment, are sufficiently severe that the patient is not likely to maintain abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus and include residual psychiatric symptoms. For dimension 4, the patient was admitted voluntarily as he relapsed with alcohol two months earlier and was battling worsening urges to drink and use other substances. He is unemployed and has been unable to make or maintain relationships due to his substance usage. The providers notes report that the patient has frequently expressed a desire to leave the RTC. He also frequently expressed passive suicidal ideation and has a history of self-injurious behaviors. The patient demonstrates passive or active opposition to addressing the severity of his mental or addiction problem or does not recognize the need for treatment. Such continued substance use poses a danger of harm to self or others. However, assessment indicates that treatment interventions available at Level 3.5 may increase the patients degree of readiness to change. For dimension 5, the patient has been using alcohol since age 13 and he previously used methamphetamine and cannabis. He has a history of several prior attempts at sobriety, most recently in 2019. He is currently being stabilized for his bipolar disorder and PTSD, which should help with his impulsivity and mood stability. He continues to have episodic passive suicidal ideation while at the RTC as well as anger outbursts when his family members expressed disagreement with him. The patient is experiencing psychiatric symptoms of insufficient ability to postpone immediate gratification. This situation poses an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structures support. The introduction of psychopharmacologic support is indicated to decrease psychiatric symptoms that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors. For dimension 6, the patient is living with his parents and his father drinks alcohol with him. He also drinks in response to his parents disagreements. He is unemployed and cannot identify any positive social supports in the community. The patients social network involves living with an individual who is a regular user such that his recovery goals are assessed as unachievable. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the dual diagnosis 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.