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 demonstrated post-acute withdrawal symptoms of cravings, anxiety, insomnia, and tremulousness. The patients withdrawal needs can be safely met in a level 3.1 setting. For dimension 2, the patient was hospitalized in the ICU for hepatorenal syndrome, alcoholic hepatitis, and he has experienced withdrawal seizures. He was transferred to the RTC once he was medically stable. The patients biomedical problems are stable and do not require medical or nurse monitoring. For dimension 3, the patient was noted to have anxiety and insomnia while in the RTC. He participated in the groups and treatment programming. He has pending legal charges related to his substance use disorder. The patients mental status is sufficient to permit participation in therapeutic interventions. The patients psychiatric condition is stable as evidenced by anxiety and guilt related to his substance use problems with imminent likelihood of relapse with dangerous consequences outside of a structured environment. For dimension 4, the patient voluntarily presented to the RTC after an ICU admission for acute liver failure due to his alcohol use. The patient acknowledges the existence of a substance use problem. He recognizes specific negative consequences and he is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient appears to have had one prior attempt at treatment and relapsed in February 2020. The providers noted that the patient has limited coping skills and understanding of relapse triggers. The patient demonstrates limited coping skills to address relapse triggers and urges. He thus is in imminent danger of relapse with dangerous emotional consequences and needs 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient is unemployed and lives alone. All of his friends are drinkers and he lacks a sober support system. The patient has high-risk social contacts that jeopardize his recovery. The patients social network includes many friends who are regular uses of alcohol leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, 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 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.