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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.5 criteria for the Residential Treatment Center services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient was treated with a benzodiazepine taper after his transfer from the hospital. He had post-acute withdrawal syndrome (PAWS) symptoms of diaphoresis, tremors and anxiety. The patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient fractured his clavicle when he fell due to a grand mal seizure. He complained of significant pain from this injury. The patient was noted to have had two alcohol withdrawal seizures. The patients biomedical problems, if any, were stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient was diagnosed with major depression while he was in the residential treatment center, and he was started on the medication Lexapro. The patient had passive suicidal ideation. He had been experiencing severe stress due to being furloughed during the COVID-19 pandemic and he had financial problems as a result. He had been drinking in the morning on a daily basis to avoid coping with his stressors. He had been drinking a fifth of whisky and had frequent blackouts. The patient had alcohol withdrawal seizures that were witnessed upon his first attempt to be admitted to the facility. He was noted to be avoidant and to have difficulty tolerating negative emotional states. He made statements about going home to drink when faced with stress while in the facility. The patients mental status permitted participation. The patients psychiatric condition was stabilizing. However, despite his best efforts, the patient was unable to control his use of alcohol and other drugs, with an attendant probability of imminent danger. The resulting level of dysfunction was so severe that it precluded the patient's participation in a less structured and intensive level of care.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily due to his inability to stop drinking on his own. He had been drinking a fifth of whiskey daily and experiencing blackouts. He had recent alcohol withdrawal seizures and fractured his clavicle. He was extremely depressed on admission and expressed passive suicidality. He was noted to have very limited insight into his use of alcohol to cope with stressors. He also had poor understanding of his relapse triggers and of his need for a sober support system. The patient made statements about leaving the facility to go drink in response to news about his insurance status. Despite experiencing serious consequences of his addictive disorder, the patient had marked difficulty in understanding the relationship between his alcohol use disorder and his impaired coping skills and level of functioning.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient had two prior residential treatment center stays. He was sober for six months after his most recent residential treatment center stay and was unclear about the reason for his most recent relapse. He had been prescribed naltrexone previously but did not take it due to possible side effects. The patient was having ongoing cravings and urges to drink. He was willing to start anti-craving medications during this treatment stay. The patients circumstances posed an imminent danger of harm to him in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support was indicated to decrease the patients addictive symptoms, such as cravings, and to enable the patient to delay immediate gratification and reinforce positive recovery behaviors.For dimension 6 - Recovery Environment. The patient was living with three roommates who all drank alcohol and smoked marijuana on a routine basis. They were all furloughed from work during the COVID-19 pandemic and were reported to be home drinking and using marijuana. The patient was employed as a bartender. His entire social network consisted of drinkers. The patient's social network included regular users of alcohol and other drugs such that the patients recovery goals were unachievable at a less intensive level of care.Using the ASAM level 3.5 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.5 treatment. Accordingly, the Residential Treatment Center (RTC) services at issue were medically necessary for the patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry 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.