Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient met Level 3.1 criteria for the Residential Treatment Center (RTC) services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient was admitted to the facility and underwent withdrawal management with Librium for alcohol withdrawal. Based on clinical findings, the patients withdrawal needs could be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient did not have any ongoing medical problems. The patients biomedical problems were therefore stable and did not require medical or nurse monitoring.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient had been drinking a fifth of vodka daily for the past one-and-a-half months and drinking heavily for 12 years. He had not able to maintain sobriety in his home environment for more than two to three days at a time. He had been drinking to manage low self-esteem, sadness, and loneliness. He had a significant history of childhood physical and mental abuse. He participated in groups. The patient met the subcriteria of having mental status that was stable enough to permit participation. At the same time, the patient's symptoms and functional limitations, when considered in the context of his home environment, were sufficiently severe that he was assessed as not likely to maintain abstinence if treatment was provided in a nonresidential setting. The patients functional limitations included residual psychiatric symptoms, chronic addictive disorder and the sequelae of physical or emotional trauma.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily after his friends had an intervention and requested that he get treatment again. The patient had been to detoxification centers and short stay residential treatment a few times, but had only been able to maintain sobriety for two to three days at a time on his own. The patient was described as being in the contemplative stage of change. He was able to identify specific negative consequences of his alcohol usage including occupational problems. The patient acknowledged the existence of his substance use problem. He also recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. Records indicate that the patient was also sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient had been drinking a fifth of vodka daily for the last one-and-a-half months and had been drinking heavily since the age of 21. He had tried to quit during the prior year by going to detoxification centers and brief residential treatment stays, but he was unable to have more than two to three days of sobriety at a time after discharge due to his inability to control impulses to drink. The patient had ongoing negative and self-deprecatory thoughts that he managed with alcohol. The patient therefore demonstrated limited coping skills to address relapse triggers and urges, and he was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to help him apply recovery and coping skills.For dimension 6 - Recovery Environment. The patient was living alone, he was socially isolated, and he had dysfunctional family relationships. He was on medical leave from work due to his alcohol use disorder. The patient therefore met the subcriteria of being able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. The patient's social network was characterized by significant social isolation and withdrawal.Using the ASAM level 3.1 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.1 treatment. Accordingly, the residential treatment center (RTC) services at issue were medically necessary for the patients medical condition.Final Result: The reviewer determined that the services at issue were medically necessary for the patient's 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 condition.