Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Residential Treatment Center (RTC) level of care services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.5 criteria for the Residential Treatment Center services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient's last drink was prior to his initial admission to a Residential Treatment Center level of care. The patient then had an alcohol withdrawal seizure and was subsequently managed at an inpatient level of care until readmission. The patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient had an alcohol withdrawal seizure and that he was discharged from an inpatient unit on the medication Keppra. The patients biomedical problems, if any, were stable.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient was diagnosed with depressive disorder and generalized anxiety disorder. He believed that he had been depressed his entire adult life and was using alcohol to cope. Prior to his admission to the Residential Treatment Center, he had told his mother that he had suicidal ideation with thoughts of shooting himself with one of the guns at their ranch. The patient had intermittent passive suicidal ideation during his stay. He was also noted to be withdrawn, guarded, and to have difficulty expressing his feelings. The patients mental status permitted participation. The patient also had significant functional deficits that were likely to respond to staff intervention. These deficits, when considered in the context of his home environment, were sufficiently severe that the patient was not likely to maintain abstinence if treatment was provided in a non-residential setting.For dimension 4 - Readiness to Change. The patient only agreed to Residential Treatment Center admission because his mother insisted that he obtain treatment after he expressed suicidal ideation to her. He had also recently passed out behind the wheel of a car and lost his job, such that he had to move in with his parents. The patient also suffered severe alcohol withdrawal seizures. He was assessed as being in the pre-contemplative stage of change and was noted to be in denial and to lack insight despite the negative consequences he had suffered. The patient demonstrated passive or active opposition to addressing the severity of his addiction problem, and his continued substance use posed a danger of harm to himself or others. However, assessment indicated that treatment interventions available at Level 3.5 could increase the patient's degree of readiness to change.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient had not had any period of sobriety in the past five years. He had never been in treatment. He acknowledged cravings to drink while he was in the facility and he was started on naltrexone. The patient was diagnosed with depressive disorder and generalized anxiety disorder while he was in the facility, and he was started on the medication Effexor. The patient had not yet developed coping skills for managing relapse triggers. He had engaged in driving under the influence and had developed suicidal ideation with thoughts of shooting himself while under the influence. The patient's psychiatric condition was stabilizing. However, despite his best efforts, the patient was unable to control his use of alcohol or other drugs, with the attendant probability of harm to himself or others. The patient had limited ability to interrupt the relapse process or to use peer supports when he was at risk for relapse to his addiction. His continued substance use posed an imminent danger of harm to himself or others in the absence of 24-hour monitoring and structured support.For dimension 6 - Recovery Environment. The patient was unemployed, and he had recently moved back in with his family at their family ranch. His social network consisted of other ranch workers where he was living on the ranch. His family also consumed alcohol and there was alcohol in the residence. He was otherwise socially isolated. The patient's social network therefore included regular users of alcohol and other drugs such that the patients recovery goals would not be achievable at a less intensive level of care.Using the ASAM level 3.5 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.5 treatment. Accordingly, the Residential Treatment Center (RTC) level of care services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's 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.