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. Per 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 had been drinking one to two bottles of wine daily for the past ten to fifteen years. She was noted to have withdrawal symptoms of nausea, agitation, sweating, and tremors and was managed with a Librium taper. The patients withdrawal needs were safely managed in level 3.5 setting. For dimension 2, the patient had Barrett's esophagus and was status post gastric bypass surgery. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had diagnoses of major depressive disorder, generalized anxiety disorder, and an unspecified cognitive disorder. She presented initially as disoriented and confused. She had persistent significant memory impairment. She did not endorse any hobbies and struggled to identify daily activities other than drinking. The patients mental status was stable enough to permit participation, and she had significant functional deficits of a pervasive nature that were sufficiently severe that she was not likely to maintain abstinence in a non-residential setting. For dimension 4, the patient presented for treatment at her familys request. She reported drinking one to two bottles of wine daily for the past ten to fifteen years, with recent worsening of cognition so that her driving was impaired. She reported being retired and struggled to identify daily activities other than drinking. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions had not succeeded at less intensive levels of care. For dimension 5, the patient had been using alcohol since age 19, and reported drinking heavily for the past ten to fifteen years. She had made three attempts at sobriety, but had subsequently relapsed. She had developed impairments in her memory impairment. She reported incidents of blacking out and was using alcohol to cope with low self-esteem. She continued experiencing carvings for alcohol and was started on naltrexone to help manage cravings. The patient continued to experience cravings for 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 was retired and living alone. She was isolated with little structure and no longer able to drive safely due to cognitive impairment. The patients social network was characterized by significant social isolation or withdrawal, 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 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 condition.