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 3.1 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 was treated for alcohol withdrawal with diazepam earlier in his treatment stay. The patients withdrawal needs can be safely managed in Level 3.1 setting. For dimension 2, the patient has hepatitis C, stage IV cirrhosis, and hypertension. He has been unable to stop drinking despite knowledge of his hepatic disease. The patients biomedical problems are stable and do not require medical or nurse monitoring. For dimension 3, the patient reported passive suicidal ideation prior to entering treatment. He reports not bathing or eating for days at a time and difficulty sleeping. The patient reported that his father was abusive, and his mother left the family when he was six-years-old. He has been drinking and using cannabis heavily since adolescence. He lacks coping skills or knowledge of relapse triggers. He participated in groups. The patients mental status has been assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients symptoms and functional limitations, when considered in the context of his home environment, are sufficiently severe that he is assessed as not likely to maintain abstinence if treatment provided in a nonresidential setting. Functional limitations may include chronic addictive disorder and sequelae of emotional trauma. For dimension 4, the patient voluntarily admitted himself for treatment due to his inability to stop drinking despite recent diagnosis of hepatitis C and cirrhosis. He was able to acknowledge negative consequences of his substance usage including prior legal problems, accident from driving while impaired, and significant hepatic disease secondary to his alcohol usage. The patient acknowledges the existence of a substance use problem. He recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient endorsed drinking a fifth of whiskey and using cannabis products daily since adolescence. His longest period of sobriety was three-weeks. He reports being unable to stop drinking despite his diagnosis of hepatitis C and cirrhosis. He bruised his ribs in a recent ATV accident in which he was operating the vehicle intoxicated. He also admits to drinking and driving in the community. The patient demonstrates limited coping skills to address relapse triggers and urges. He thus is in imminent danger of relapse with dangerous emotional, behavioral, and cognitive consequences and needs 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient lives with his fiance who drinks. He owns and works on a cannabis farm and many of the workers drink while at work. He does not appear to have a sober social support network. He is reported as having no knowledge of coping skills or relapse triggers as this is his first attempt at treatment. He was unable to achieve even a single day of sobriety on his own after the hepatitis C diagnosis one month prior to admission. The patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities. Continued exposure to the patients living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. These findings support that the patient meets the six ASAM dimensions for RTC services. Moreover, the RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and are not primarily for convenience of the patient or provider. 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.