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 3.5 criteria for RTC services. For dimension 1, the patient underwent withdrawal management for alcohol withdrawal earlier in their treatment stay. The patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient does not have medical problems. The patients biomedical problems, if any, are stable, and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering prescribed medications. For dimension 3, The patient has been diagnosed with anxiety disorder and depressive disorder.  They have been drinking three bottles of wine daily. They sustained a blackout so severe that they woke up in the hospital prior to admission. The patient has incurred legal charges due to their alcohol use disorder. The provider noted that the patient continues to be impulsive regarding their treatment. The patient demonstrates repeated inability to control their impulses to use alcohol and other drugs or to engage in antisocial behavior and is in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction is of such severity that it precludes participation in treatment in the absence of 24-hour support and structure of a Level 3.5 program. For dimension 4, the patient was voluntarily admitted for treatment after becoming extremely depressed during their most recent relapse. The patient reportedly relapsed after a six-day admission in 2021. The patient endorsed drinking up to three bottles of wine daily. Since their last admission, the patient blacked out and woke up in the hospital. The patient minimizes and denies the extent of their alcohol use. The records support that because of the intensity and chronicity of the addictive disorder, the patient has limited insight and little awareness of the need for continuing care or the existence of their substance use and need for treatment, and thus has limited readiness to change. For dimension 5, the patient indicated that they relapsed after their six-day admission in 2021. They endorsed drinking three bottles of wine daily. They minimize and deny alcohol use and are  not able to honestly identify their relapse triggers. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. Their continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient recently broke up with an abusive partner and their only sober support is their mother. The patients social circle consists of others who drink alcohol. They consistently relapsed when in their home environment. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the ASAM criteria for RTC services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the RTC services (ASAM 3.5) 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.