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. 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 patients withdrawal needs can safely be managed in a level 3.5 setting. The patient was admitted to RTC from the emergency department in stable condition. For dimension 2, the patient reportedly experienced a recent serious loss of consciousness and hematoma due to alcohol intoxication. Per ASAM, traumatic brain injury (TBI) is one of the important neurological complications associated with alcohol abuse. In addition to her pre-existing poor self-care, the patient continues to require assistance to ensure adherence to medication and self-care. A current biomedical condition is not severe enough to warrant inpatient treatment but is sufficient to distract from treatment or recovery efforts. The problem requires medical monitoring, which can be provided by the program or through an established arrangement. For dimension 3, despite her closed head trauma, the patients mental status is sufficient to permit her to participate in the therapeutic milieu and interventions at this level of care. The patient has demonstrated repeated inability to control her impulses to use alcohol and is at imminent danger of relapse, with the attendant likelihood of self-harm, as evidenced by her recent head trauma and history of previous similar instances. Per the provider, the patient was unable to engage in adequate self-care in a lower level of care and was malnourished. These factors in combination with level of intoxication contributed to her recent fall and head trauma. For dimension 4, despite experiencing serious consequences or effects from her alcohol use disorder, the patient has marked difficulty in understanding the relationship between her substance use and life problems. The records document that the patient often blames her family members for her addiction problems. The provider described the patient as angry, impulsive, and a danger to herself as evidenced by her jumping out of a moving car on the way to RTC admission. For dimension 5, the patient is reporting cravings of 10/10 severity and she has been unable to postpone immediate gratification without 24-hour support. Despite recent, active participation in treatment at a less intensive level of care, the patient continues to use alcohol, with imminent serious consequences, and is at high risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. The patient is at imminent danger to herself as evidenced by her repeated head trauma due to intoxication. Moreover, the patient has failed lower levels of care and previous rehabilitation, thus has limited ability to interrupt the relapse process or continued use, or to use peer supports when at risk for relapse. For dimension 6, the patients social network is characterized by significant social isolation and withdrawal, such that recovery goals are not achievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC level of care services. Therefore, the RTC services 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.