Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) level of services.With regard to dimension 1, acute intoxication and/or withdrawal potential, the patient was three weeks out from use of alcohol or cannabis, and he did not have any post-acute withdrawal symptoms. Based on clinical findings, the patients withdrawal needs could be met in the level 3.5 residential treatment center setting.In terms of dimension 2, biomedical conditions and complications, the patient had a history of Langerhans cell tumor, but he was in remission for several years prior to admission. He reported no physical complaints and took no medications. Based on clinical findings, the patient meets this dimension, as his biomedical problems were stable and did not require 24-hour medical or nurse monitoring.With regard to dimension 3, emotional/behavioral/cognitive conditions and complications, the patient had initially presented complaints of depressive symptoms with poor concentration, apathy, depressed mood, and anhedonia. Prior to admission he had been having difficulty attending work. He was also using substances to treat his psychiatric symptoms. On his most recent binge of alcohol, he woke up in the street with his wallet missing. Based on clinical findings, the patient met both the sub-criteria that requires mental status that was sufficiently stable to permit participation, and the sub-criteria that he demonstrated repeated inability to control his impulses to use alcohol and drugs, with attendant likelihood of harm to self, others, or property.In terms of dimension 4, readiness to change, the patient was willing to enter treatment and explore strategies for changing his use of alcohol. He was unsure about his need to change marijuana usage. He had been using alcohol and cannabis on a daily or near daily basis for several years. Based on clinical findings, the patient met the sub-criteria that, because of the intensity and chronicity of his addictive disorder, he had limited insight and thus had limited readiness to change.With regard to dimension 5, relapse/continued use/continued problem potential, the patient had good insight into his alcohol use disorder. While he was questioning his need to change marijuana usage, he was no longer having urges to use alcohol. He indicated that he was not interested in psychotropic medication for his depression, anxiety, or to prevent cravings to use alcohol. He was engaging in binge drinking prior to this treatment, and he was found unconscious on the street with his wallet missing. Based on clinical findings, the patient met the sub-criteria under which the patient was in imminent danger of relapse, with dangerous behavioral consequences.In terms of dimension 6, recovery environment, the patient had been living in an apartment in Seattle, Washington, and he worked in the food industry. His social network consisted of people who also used alcohol and substances. Based on clinical findings, the patient met the sub-criteria under which the patients social network included regular users of alcohol and other drugs such that recovery goals were unachievable at a less intensive level of care.In this case, using the ASAM 3.5 criteria, the patient met all six dimensions for level 3.5 residential treatment center (RTC) level of services. Accordingly, the residential treatment center (RTC) services at issue were medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat 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.