Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) level of care services with high-intensity residential with biomedical enhanced services (equivalent to ASAM 3.5). Findings:  The physician reviewer found that he American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for RTC services provided from 9/11/20 forward. 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. Applying the ASAM framework, the patient meets the criteria for Level 3.5 level of care RTC services.For dimension 1, the patients withdrawal symptoms may be managed at the Level 3.5 and she does not require 24-hour medical or nurse monitoring. For dimension 2, the patients biomedical conditions include dysphagia, confusion, lethargy and intermittent nausea. The patient has a history of pancytopenia due to B12 deficiency and alcohol use, and she required an endoscopy in 2019 related to her hematochezia and melena. The patients current biomedical conditions are not severe enough to require inpatient treatment but are sufficient to distract from her treatment and recovery efforts. The patients biomedical problems require medical monitoring, which can be provided by the program at her current RTC. For dimension 3, the patients mental status is sufficient to permit her participation in the therapeutic interventions provided at this level of care. The patient has significant functional deficits, which have responded to staff interventions. These symptoms and deficits, when considered in the context of her home environment, are sufficiently severe that the patient is not likely to maintain mental stability and abstinence if treatment is provided in a non-residential setting. The provider described the patient as wandering and lost, disoriented, and confused. The patient has difficulty swallowing due to Barretts esophagus and she requires assistance with medication adherence, including naltrexone. She also experienced depressive symptoms of anhedonia, depression, low self-esteem, and guilt. For dimension 4, the patient requires structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery because motivational interventions have not succeeded at less intensive levels of care and such interventions are not likely to succeed at a less intensive level of care. Prior to admission, the patient was living alone and isolating. The patient has a history of impulsivity, which includes driving while under the influence, blacking out from substance use, and having sex with multiple partners. The patients cognitive deficits included wandering and confusion about her whereabouts.  For dimension 5, the patient has been experiencing cravings related to protracted withdrawal as evidenced by symptoms including anxiety irritability, headache, nausea, paroxysmal sweating and tremor. The patient has reported auditory disturbances. The patient has a history of falls while intoxicated, but she has been unable to take all of her medications reliably without 24-hour support. The patient is experiencing psychiatric and addiction symptoms such as drug craving, insufficient ability to postpone immediate gratification, and other drug-seeking behaviors. The situation poses an imminent danger of harm to self and others in the absence of 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors. These services are being provided at the patients current RTC facility at the 3.5 level of care. For dimension 6, the patients social environment is remarkable for significant social isolation or withdrawal, such that recovery goals are assessed as inconsistently achievable at a less intensive level of care. The patient has been unable to cope, for even limited periods of time, outside of 24-hour level of care. She needs staff monitoring to learn to cope with her Dimension 6 problems before being safely transferred to a less intensive setting.  Her drinking has caused deterioration of family relationships and her family will not let her see her grandchildren due to her drinking. Her drinking has resulted in hepatic dysfunction, which was coupled with poor diet, resulted in progressive cognitive decline that prompted a medical admission for encephalopathy.  In addition, given her gastric bypass surgery, it is imperative that she take the appropriate dietary supplements and avoid alcohol in order for her to prevent further decline in health and function. Given these findings, the patient meets the six ASAM dimensions for RTC level of care services. All told, the RTC level of care services with high-intensity residential with biomedical enhanced services (equivalent to ASAM 3.5) were and are 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 with subspecialty certification in addition 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.