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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for dual diagnosis residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.1 or 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, as of the last clinical notes, the patient reported drinking 15 to 20 twelve ounce beers daily for the past five months. While the patient has a significant history of alcohol withdrawal, there is insufficient information based on available records to assess the patients current withdrawal risk and whether the patients withdrawal needs can be safely met in a Level 3.1 setting. For dimension 2, while the patient has a history of gastropathy and hematemesis, no current symptoms were noted as of the last clinical notes. This requirement is not satisfied based on the available records. For dimension 3, the patient has diagnoses of borderline personality disorder and generalized anxiety disorder. The last clinical notes reported that she was not suicidal or homicidal. She reported engaging in self-harming behavior and had relationship difficulties with her daughter. She was working full time. There is insufficient information based on available records to assess if the patients mental status is currently stable enough to permit participation in a Level 3.1 setting.For dimension 4, the patient presented in the last clinical notes seeking treatment for her alcohol use disorder. She acknowledged her diagnosis of borderline personality disorder. Given that her last clinical encounter was four months ago, there is insufficient information based on the available records to assess the patients readiness to change.  For dimension 5, the patient reported that she had been sober for eight months during the previous year, but as of the last clinical notes had relapsed five months prior and was drinking 15 to 20 twelve ounce beers daily. Given that her last clinical encounter was four months ago, there is insufficient information based on the available records to assess the emotional and behavioral consequences in the absence of close 24-hour monitoring and structured treatment.For dimension 6, the patient lived with a roommate who acted as an advocate for her. She was working full-time. Given that her last clinical encounter was four months ago, there is insufficient information based on the available records to assess whether continued exposure to her work or living environment makes recovery unlikely.Given these findings, the patient does not meet the six ASAM dimensions for RTC services. Accordingly, dual diagnosis RTC services are not medically necessary to treat the patients mental health or substance use disorder for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms, in a manner that is all of the following: (i) in accordance with the generally accepted standards of mental health and substance use disorder care; (ii) clinically appropriate in terms of type, frequency, extent, site, and duration; (iii) not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.