Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for RTC level of care. Findings:  The physician reviewer found that per American Society of Addiction Medicine (ASAM) criteria, this patient met and meets Level 3.5 criteria for RTC level of care. 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 noted to have mild to moderate withdrawal symptoms of agitation, anxiety, diaphoresis, and tremors. She was on a chlordiazepoxide taper for withdrawal symptoms. The patients withdrawal needs were safely managed in level 3.5 setting. For dimension 2, the patient does not have biomedical problems and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with depressive disorder, anxiety, and PTSD. Her medications included acamprosate, buspirone, duloxetine, trazodone, and propranolol. She was using alcohol to manage her anxiety, and she relapsed during the COVID-19 quarantine due to isolation. She reported severe abuse in her relationships. Notes showed the patient participated in high intensity residential rehabilitation to address her PTSD. While the patients mental status was stable enough to permit participation, she had significant functional deficits of a pervasive nature, including residual psychiatric symptoms and the sequelae of trauma that were likely to respond to staff interventions. For dimension 4, the patient reported drinking heavily for the past one to two years. She had a history of attempts at recovery and relapse, and was noted as being prone to codependent manifestations. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions had not succeeded at less intensive levels of care. For dimension 5, the patient was in an IOP but COVID-19 caused these programs to close, resulting in relapse. She had a history of blackouts. She was experiencing cravings and started on Campral to reduce cravings. Despite recent, active, participation in treatment at a less intensive level of care, the patient was at high-risk of continued alcohol use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient lived with her three adult children, and her social network included regular drinkers, such that recovery goals were assessed as unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM criteria for RTC level of care. Accordingly, RTC level of care was and is medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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.