Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that : The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM Level 3.3) provided at The Lakes Treatment Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.3 criteria for RTC services from 10/14/21 going 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. For dimension 1, the patient was managed for alcohol withdrawal with lorazepam earlier in RTC stay. The patients withdrawal needs were and are safely managed in a Level 3.3 setting. For dimension 2, the patient has cirrhosis of the liver and a history of brain injury. The patients biomedical problems were and are stable and do not require medical or nurse monitoring. For dimension 3, the patient was noted as having significant short term memory impairment. The patient had been dependent on substances since adolescence and lacked coping skills or knowledge of relapse triggers. The patient participated in group therapy. The patients mental status was and is stable enough to permit participation, and symptoms and functional limitations, when considered in the context of the patient's home environment, were and are sufficiently severe that the patient is assessed as not likely to maintain abstinence in a nonresidential setting. For dimension 4, the patient reported self-admission for treatment to escape a physically abusive relationship with a man the patient met at an AA meeting. The records noted that the patients family was selling the patient's home. The patient blamed ongoing alcohol use on losses, family, and others. The patients perspective impairs ability to make behavior changes without repeated structured, clinically directed motivational interventions, delivered in a 24-hour milieu.For dimension 5, the patient reported relapsing after two pets passed away. The records noted that in the past, the patient had fallen and hit their head during a blackout episode of intoxication. The patient had been manipulated by a man met at an AA meeting to drink and return home with him, leading to a physical abuse and an inability to escape the situation without the help of friends. The patients cognitive impairment has limited the patient's ability to identify and cope with relapse triggers and high risk situations. The patient requires relapse prevention activities that are delivered at a slower pace, more concretely, and more repetitively in a setting that provides 24-hour structure and support to prevent imminent dangerous consequences.For dimension 6, the patient was rescued from an abusive relationship by sober friends and stayed with them until a RTC was found. The patient had relapsed after attending an AA meeting and has been taken advantage of by others in the community prior to this incident. The patient does not have a local sober social support network. Because of cognitive limitations, the patient was and is in danger of victimization by another and thus requires 24-hour supervision.Given these findings, the patient meets the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, the RTC (ASAM Level 3.3) provided at The Lakes Treatment Center 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.