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 meets 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 completed withdrawal management. The patients withdrawal needs could have been safely managed in a Level 3.1 setting. For dimension 2, the patient has diagnoses of hypertension, obesity, and glaucoma. The patients biomedical problems 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 has a history of recurrent major depression and he has been grieving the traumatic loss of his daughter in a hit and run accident that he witnessed in October 2020. He was using alcohol to manage the trauma and grief of this loss. He participated in groups. The patients mental status was assessed as sufficiently stable to allow 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 his home environment, were sufficiently severe that he was assessed as not likely to maintain mental stability and abstinence if treatment was provided in a nonresidential setting. Functional limitations may include chronic addictive disorder and sequelae of emotional trauma. For dimension 4, the patient admitted himself for treatment after his siblings staged an intervention due to concerns about his escalating alcohol usage. Throughout most of his treatment stay, he expressed that he did not believe that he had an alcohol use disorder and attributed his alcohol usage to the trauma of witnessing his daughters death. The patients perspective impaired his ability to make behavior changes without the support of a structured environment. For example, the patient attributed his alcohol problem to external events, rather than a substance use disorder, interventions were assessed as not likely to succeed in an outpatient setting. For dimension 5, the patient endorsed drinking six drinks daily since the traumatic death of his daughter. The provider noted that the patient lacked coping skills to manage his grief and loss as he had been drinking on a daily basis for decades. The patient understood his addiction and mental disorder but was at risk of relapse in a less structured level of care because he was unable to consistently address either or both. For dimension 6, the patient was living alone after his wife moved out with their teenage daughter one month prior to his RTC admission. The patients entire family drinks and his social life revolves around alcohol. He is otherwise socially isolated. 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 lacked social contacts or had high-risk social contacts that jeopardized his recovery. The patients social network included many friends and family members that are regular users of alcohol leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting. Given these findings, the patient met the six ASAM dimensions for RTC services. All told, the RTC services were medically necessary for 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 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.