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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for residential treatment center (RTC) services. Findings:  The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 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 was sober more than two months and was not at risk for withdrawal. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient has sleep apnea and had recent clavicle surgery. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of administering any prescribed medications. For dimension 3, the patients mental status is assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has no psychiatric complaints or reported psychiatric history. He does not have a diagnosed psychiatric condition. He does not have history of antisocial behavior patterns. He has been able to maintain sobriety in the community setting. He does not have any functional deficits. He is not noted to have impulse control difficulties. He does not meet the dimension three criteria. For dimension 4, the patient recently left an RTC against medical advice due to dislike of bedding and dietary issues. He then actively participated in the IOP programs. He appears to have good insight and awareness of need for treatment. He appears to be working on coping skills. He is not demonstrating opposition to addressing the severity of his alcohol use disorder. He appears to be successfully employing motivational interventions at his current level of care. He does not appear to need structure therapy and a 24-hour programmatic milieu to promote behavioral changes. He expresses interest in changing. He is not attributing his alcohol use disorder to other persons or external events. He does not meet any of the dimension 4 criteria. For dimension 5, the patient recently relapsed in and he was treated in an RTC. He was sober for 75 days and does not endorse cravings. He is working on recognizing relapse triggers. He does not have a psychiatric condition. He is not experiencing cravings or inability to postpone immediate gratification. He does not appear to be in imminent danger of relapse. He does not have a history of repeated incarcerations and relapse on substances. He does not meet any of the dimension 5 criteria.For dimension 6, the patient lives with his mother who appears to be supportive of his treatment. He is participating in groups in the community setting. He is unemployed as a server due to quarantine and he is considering a job change. There is no reported abuse in his recovery environment. He is not living with an active user and does not appear to have a social network composed of active users. He is not socially withdrawn. He does not meet any of the dimension 6 criteria.Given these findings, the patient does not meet ASAM criteria for RTC services. the adult ASAM 3.5 criteria require that all six dimensional criteria are met. In this case, the patient did not meet all six dimensions. Therefore, the requested RTC level of care is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.