Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any or all of the RTC services provided by The Lakes Treatment Center. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 admitted to the RTC and reported that his last drink was day prior. He completed a Librium taper. The patients withdrawal needs were safely managed in level 3.1 setting. For dimension 2, the patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had a history of hospitalization for anxiety. His medications included Lexapro. He participated in groups and increased his drinking in response to feeling depressed over a breakup several months prior. The patients mental status was stable enough to permit participation, his psychiatric condition was stable, and he was not assessed as posing a risk to himself or others. For dimension 4, the patient admitted himself voluntarily for RTC treatment and reported his heavy alcohol usage negatively affected his relationships and employment. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care. For dimension 5, the patient had been drinking a half pint of whiskey and hard seltzers daily. He reported trying to quit on his own. At the RTC, he had trouble regulating his emotions. He was at risk of relapse due to his employment as a bartender and a lack of sober supports. This was his first attempt at formal treatment. Despite recent, active, attempts at informal treatment, the patient continued to use alcohol with imminent serious consequences and was at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient lived with his mother and worked as a bartender. His social group consisted of coworkers who drank. The patients social network included regular users of alcohol such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM criteria for RTC services. Accordingly, all of the RTC services provided by The Lakes Treatment Center were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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 con