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 and managed for withdrawal with a five-day lorazepam taper. She experienced withdrawal symptoms of insomnia, anxiety, and agitation. The patients withdrawal needs could have been met in Level 3.1 setting. For dimension 2, the patient does not have any medical problems. The patients biomedical problems are stable and do not require medical or nurse monitoring. Biomedical problems, if any, 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 had complaints of depression and anxiety. The provider noted that the patient has experienced physical abuse in her home. During treatment, she was described as constantly anxious. She participated in groups. The patients mental status was 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 patients symptoms and functional limitations, when considered in the context of her home environment, were sufficiently severe that she was assessed as not likely to maintain mental stability and abstinence if treatment was provided in a nonresidential setting. Functional limitations may include the sequelae of physical, sexual, or emotional trauma. For dimension 4, the patient admitted herself for treatment of her alcohol use disorder as she was unable to stop drinking on her own. She is expressing desire to become abstinent as she was drinking up to seven drinks per day prior to admission. The patient acknowledged the existence of a substance use problem. She was able to identify negative consequences of her alcohol usage including legal problems and relationship problems. The patient 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 seven drinks on a daily basis for the past three years. She has only had a one-week period of sobriety. This is her first attempt at sobriety, and she did not have any concept of recovery. She did not have any skills of managing urges to drink. 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 lives with her family, with whom she has a history of abuse. 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 patient was living in an environment that is characterized by repetition of physical or emotional abuse that the patient was assessed as being unable to achieve or maintain recovery at a less intensive level of care. These findings support that the patient met the six ASAM dimensions for RTC services. Therefore, the substance abuse detoxification RTC services and substance abuse subacute RTC services were medically necessary for 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.