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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the 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 had no signs of acute withdrawal from alcohol that required treatment at a higher level of care. The patients last use of alcohol was the day before his admission for RTC services. He did not require medication for withdrawal management. The patients withdrawal needs could have been met in a Level 3.1 setting. For dimension 2, the patient had no biomedical problems. For dimension 3, the patients mental status was sufficient to permit participation in the therapeutic interventions provided in a Level 3.1 setting. The patient reported depression, anxiety, and ongoing passive suicidal thoughts. He reported inability to stop drinking on his own due to lack of impulse control. He was unable to maintain stable behavior in a less structured and supportive level of care. For dimension 4, the patient was in a contemplative stage of change and reported an inability to stop drinking on his own. He acknowledged the existence of a substance use problem, and was sufficiently ready to change, and cooperative enough to respond to treatment in a Level 3.1 setting. For dimension 5, the patient had started drinking at age 15 and noticed problematic usage beginning in his early twenties. He had been unable to quit drinking on his own due to poor impulse control. He demonstrated limited coping skills to address relapse triggers and was thus in imminent danger of relapse with dangerous emotional consequences, requiring 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient lived alone and was socially isolated with limited supports. He was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program. The patient was living in an environment that allowed him to easily access alcohol and had insufficient skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC services provided were medically necessary for the treatment of 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 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.