Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for ASAM Level 3.5 residential treatment center (RTC) services. Findings:  The physician reviewer found that American Society of Addiction Medicine (ASAM) criteria, this patient met 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 patient underwent management for alcohol withdrawal earlier in the RTC stay. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had bulimia and was actively purging, but did not have any emergent medical issues. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient has a diagnosis of bulimia. She continued to purge daily while at the RTC. She has the medical sequelae of bulimia including dental problems and nodules in her throat. The patient reported drinking to limit her appetite for food and to facilitate her food restriction and purging. She reported drinking a pint of liquor daily, to the point of blackouts. She reported drinking while driving and while at her job. The patients mental status was stable enough to permit participation, she demonstrated a repeated inability to control her impulses to use alcohol, and she was in imminent danger of relapse with attendant likelihood of harm to self, with a resulting level of dysfunction of such severity that it precluded participation in treatment in the absence of the 24-hour support and structure of a Level 3.5 program.For dimension 4, the patient was admitted voluntarily for treatment. She reported feeling that her alcohol use was killing her and was unable to stop drinking on her own due to withdrawal symptoms. The patient reported drinking since age 15 with usage escalating to one pint daily. The records noted significant co-morbidity of bulimia with daily purging. The patient used alcohol to facilitate her bulimic symptoms and did not recognize the severity of her eating disorder or the inter-relationship between the eating disorder and her alcohol usage. She was unable to stop purging while at the RTC and did not recognize how purging interfered with her recovery from alcohol usage. Due to the intensity and chronicity of the addictive disorder, the patient had limited insight and little awareness of the need for continuing care or the existence of her substance use and need for treatment, and thus had limited readiness to change.For dimension 5, this is the patients first treatment attempt in thirty years. She reported drinking a pint of liquor daily, to the point of blackouts, and driving while intoxicated. The patient was unable to cut down or stop drinking on her own. The patient also had significant bulimia and was purging, using alcohol to decrease her appetite and facilitate her bulimic symptoms. She refused further treatment for her eating disorder, such as a medical assessment with laboratory testing.  The patient was not able to identify relapse triggers, and was unwilling to discuss her eating disorder, reporting that she did not feel that she needed treatment for it despite its interference with her recovery from alcohol use disorder. The patient did not recognize relapse triggers, lacked insight into the benefits of continuing care, and her continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support.For dimension 6, the patient lived with her husband and reported that he was emotionally abusive and not supportive of her recovery. He refused to drive her to treatment and the patient did not want him to participate in family therapy at the RTC. The patient lived in an environment that was characterized by moderately increased risk of repetition of physical or emotional abuse such that the patient was assessed as being unable to achieve or maintain recovery at a less intensive level of care.Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, ASAM Level 3.5 RTC services were medically necessary for treatment of this patientFinal 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 condition.