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) services (ASAM Level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria this patient meets 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 underwent withdrawal management for alcohol withdrawal. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient has hypertension. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has complaints of anxiety and depression. She has been unable to cope with managing stress and emotions in her home environment and has relapsed on alcohol shortly after leaving the RTC. She has been using alcohol to manage her anxiety about her future and to manage her depression about the consequences from her alcohol use. The patients mental status has been assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has significant functional deficits, which are likely to respond 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/or abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus; they do not require medical monitoring or management. They may include residual psychiatric symptoms, chronic addictive disorder, and the sequelae of physical, sexual, or emotional trauma. For dimension 4, the patient was admitted voluntarily to RTC after she relapsed shortly after discharge from the prior RTC. She has troubled relationships with her adult children, legal and employment issues, and financial difficulties related to her alcohol use. The patient has no insight into the reason she started drinking again and lacks coping skills to prevent relapse. The provider charted that the patient blames her drinking on her divorce. Despite experiencing serious consequences or effects of the addictive disorder the patient has marked difficulty in understanding the relationship between her substance use, addiction, mental health, or life problems and her impaired coping skills and level of functioning, often blaming others for her addiction problems. For dimension 5, the patient has undergone multiple attempts at treatment. She had relapsed on alcohol shortly after discharge from RTC. The patient endorsed drinking one pint of vodka daily since 2010 except while in RTC facilities. The patient has continued to experience cravings to drink and was started on oral naltrexone followed by vivitrol injection. The patient is experiencing addiction symptoms such as drug craving. This situation poses an imminent danger of harm to self or others in the absence of close 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. For dimension 6, the patient is divorced and lives with one of her adult children with limited interaction. The patient is unemployed due to alcohol use. She has relapsed shortly after discharge from previous RTC stays and she has not been able to identify reasons for her problems. The provider noted that the patient has not followed through on discharge plans in the past. She identifies significant stress in her relationship with her children, other family members, as well as financial stress from unemployment. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. The patient needs staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services (ASAM Level 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 addiction 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.