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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) level of care services. Findings:  The physician reviewer found that this patient did 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 managed with a Librium taper, did not have ongoing signs or symptoms suggestive of significant withdrawal, and was no longer at risk for complicated withdrawal. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient had a diagnosis of herpes simplex and was prescribed valacyclovir. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had a history of childhood trauma that she had not previously addressed and tended to dissociate from. The patient did not endorse suicidal, self-injurious, homicidal, aggressive, or psychotic behavior. While the patients mental status was stable enough to permit participation, she did not demonstrate an inability to maintain stable behavior without the structure and support of a 24-hour setting, or evidence psychiatric symptoms placing her at imminent likelihood of relapse with dangerous consequences outside of a structured environment. This criterion is not met. For dimension 4, the patient admitted herself to treatment voluntarily upon learning that her husband had been involved in an extramarital affair. The patient was motivated, expressed motivation for abstinence throughout her stay, was aware of her need for treatment, and recognized the role of her alcohol use in her symptoms and behaviors. This was the patients first attempt at treatment. The patient did not require structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because she was motivated and to able to put together a coherent linear recovery plan. This criterion is not met. For dimension 5, the patient reported being sober during her pregnancy with twins and for nine days in in the previous year. The patient was described as having a good recovery plan and recognized her primary triggers involving marital stressors. The records noted the providers concern regarding the impact of COVID-19 restrictions and with the familys functioning at home. Their records did not show that the patient needed staff support to maintain engagement, or that she was consistently unable to address her mental health, substance use, or risk of relapse issues in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient lived with her husband and two children. The patient was motivated to remain sober and reported that her alcohol use had been an issue in her marriage. The patients husband had stated that he would end his extramarital affair and dedicate himself to the marriage, but the patient continued to have issues trusting her husband. The patients aftercare plan included intensive outpatient treatment, involvement with 12-step meetings, couples therapy, and individual therapy. The patients home environment was not characterized by risk of neglect, physical, sexual, or emotional abuse, or active substance use such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. This criterion is not met.Given these findings, the patient did not meet the six ASAM criteria for RTC level of care services. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, the RTC level of care services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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.