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

Findings:  The physician reviewer found that The patient has requested reimbursement and prospective authorization and coverage for low-intensity residential treatment, specifically ASAM Level 3.1. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 criteria for residential treatment center (RTC) services from 12/13/21 and forward. 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 treated for alcohol withdrawal with benzodiazepines earlier in the treatment stay. The patients post-acute withdrawal symptoms can be safely managed in a Level 3.1 treatment setting. For dimension 2, the patient is noted to have hepatitis C and hypertension. The patient has biomedical problems that are stable and do not require medical or nurse monitoring. For dimension 3, the patients mental status and psychiatric condition are sufficient to permit participation in the therapeutic interventions provided at Level 3.1. The patient is noted as having antisocial behaviors, impulsivity, and cognitive impairment due to a traumatic brain injury. The patient has a history of childhood abuse and started alcohol use during childhood. The patient reported being impulsive and having difficulty thinking of the consequences of behaviors. The records noted that the patient has a history of several incarcerations and is facing a charge of domestic violence. The patient participated in group therapy. For dimension 4, the patient self-admitted for treatment voluntarily due to declining physical health.  The patient acknowledges the existence of a substance use problem,  recognizes specific negative consequences and dysfunctional behaviors and their effect on desire to change, and is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient reported drinking a fifth of liquor daily for the past twenty years. The patient has had multiple blackouts while drinking and has a pending charge of domestic violence. The patient was noted to have difficulty with completing assignments due to cognitive deficits and in accepting advice and suggestions during group sessions. The records noted ongoing problems with impulsivity, as the patient became aggressive with staff, reflecting a lack of adequate coping skills.  The patient endorsed ongoing cravings to drink despite being on naltrexone. Overall, the patient demonstrated limited coping skills to identify and address relapse triggers and urges. The patient is in imminent danger of relapse with dangerous behavioral consequences and needs 24-hour structure to help apply recovery and coping skills. For dimension 6, the patient was living with a girlfriend of six years in Maine who also used alcohol. The patient is socially isolated, does not have a sober social support network, and is facing legal charges of domestic violence.  The patient is able to cope for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue community activities. The patient lacks social contacts or has high-risk social contacts that jeopardize recovery, and a social network is characterized by significant social isolation and withdrawal. The patient's social network includes regular users of alcohol or other drugs, such that recovery goals are to be assessed as unachievable outside of a 24-hour supportive setting.Given these findings, the patient meets the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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. Accordingly, low-intensity residential treatment, specifically ASAM Level 3.1, was and is 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.