Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 admitted to RTC. She was assessed and managed for alcohol withdrawal. She continued to have moderate withdrawal symptoms. The patients withdrawal needs could have been met in Level 3.1 setting. For dimension 2. The patient had ongoing symptoms of a retroorbital tumor, for which she was undergoing a work-up. The patients biomedical problems were stable and did not require medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has a significant history of childhood abuse and neglect. She demonstrated many symptoms of PTSD and she was using alcohol to deal with intrusive memories, mood lability, and anger dyscontrol. She made improvements in developing coping skills from participating in groups. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition was stable, and she was assessed as having minimal problems in this area, as evidenced by both of the following: the patients anxiety may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment and the patient was assessed as not posing a risk of harm to self or others. For dimension 4, the patient admitted herself voluntarily after she caused a motor vehicle accident in which the other party was injured. She expressed a desire to remain sober and was able to identify negative consequences of her addiction that also included her adult children being estranged from her. The patient acknowledged the existence of a substance use problem. She recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been drinking 18-24 beers daily for the past five years. She has been using alcohol and cannabis regularly since age 11. This was the patients first attempt at treatment since 2014. She has been using alcohol to treat her anxiety, anger, and negative emotions. She has had trouble regulating her emotional response to anger. She was having ongoing severe cravings and was assessed to start vivitrol injections. She was living in an environment with others that use alcohol and cannabis. The patient demonstrated limited coping skills to address relapse triggers and urges. She was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient was living with her boyfriend and a roommate that drink alcohol and use cannabis on a daily basis. The patient lived in a small town that only has a liquor store and a bar. She had no sober support system. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. The patients social network involved living in an environment that was so highly invested in alcohol or other drug use that the patients recovery goals were assessed as unachievable outside of a 24-hour setting. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC services were medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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.