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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.1 criteria for Residential Treatment Center (RTC) services. 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 admitted to residential treatment center care and monitored for alcohol withdrawal. The patient declined medical management of her withdrawal. Based on clinical findings, the patients withdrawal needs could be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient has denied active medical problems. The patients biomedical problems are therefore stable and do not require medical or nurse monitoring.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. While in the facility, the patient was diagnosed with major depression that is severe. The patient also had significant trauma from a sexual assault, and she has been drinking to the point of blackouts every night since then due to an inability to cope with shame and guilt. The patient was fearful of returning to the small town where she lives, as she feels that most people know what happened to her and think negatively of her. The patient meets the subcriteria of having mental status that is stable enough to permit participation. At the same time, the patient's symptoms and functional limitations, when considered in the context of her home environment, are sufficiently severe that she is assessed as not likely to maintain mental stability and abstinence if treatment is provided in a nonresidential setting. The patients functional limitations may include sequelae of sexual trauma. The patient is further assessed as not posing a risk of harm to self or others.For dimension 4 - Readiness to Change. The patient admitted herself for treatment after being unable to stop drinking on her own. She had tried on several occasions to stop drinking and was unable to do so despite recognizing negative consequences. She is currently expressing a desire to remain clean and abstinent, and she is able to identify the negative consequences of her alcohol usage including loss of relationships, jobs, and educational status. The patient recognizes specific negative consequences and dysfunctional behaviors and their effect on her desire to change. Records indicate that the patient is also sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient has been drinking 12 shots plus 8 hard ciders daily until the point of blackout for the past several years after a sexual assault. She has no prior periods of sobriety and no prior attempts at treatment. She has not yet developed coping skills for dealing with relapse triggers. She feels that living in her small town is a trigger for her and is worried about relapse if she returns there. The patient therefore demonstrates limited coping skills to address relapse triggers and urges, and she is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills.For dimension 6 - Recovery Environment. The patient lives alone and is on leave from her job as a bartender. She is socially isolated and does not have a sober support group. She associates the town in which she lives as being a trigger, as she was sexually assaulted there. The patient therefore meets the subcriteria of being able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment makes recovery unlikely, and the patient has insufficient skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Using the ASAM level 3.1 criteria worksheet, the patient meets all six criteria for medical necessity and therefore qualifies for ASAM Level 3.1 treatment. Accordingly, the requested residential treatment center services were, and are, medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue and requested services were, and are, 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.