Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the 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 withdrawal management prior to transfer to the RTC from inpatient level of care. The patients withdrawal needs could have been met in Level 3.5 setting. For dimension 2, the patient has endometriosis and she is status post ovarian resection and ablation. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with major depressive disorder and generalized anxiety disorder. The patient also had recent accidental overdose with blackout on alcohol and Klonopin that caused her to fall and sustain a concussion. She becomes suicidal while drinking on a frequent basis and she has been unable to control her drinking in the community setting. The patients mental status was assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient demonstrates repeated inability to control her impulses to use alcohol and was in imminent danger of relapse with attendant likelihood of harm to self. The resulting level of dysfunction was so severe 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 to an RTC after psychiatric inpatient level of care services due to a suicide attempt. The provider charted that the patient demonstrated poor insight into her alcohol use despite two prior RTC treatments. The patient reported having significant difficulties over the past two years due to increasing alcohol usage and worsening depression and anxiety. The patient has been managing distress from negative events by drinking alcohol, which for her, results in suicidal ideation. Despite experiencing serious consequences of the addictive disorder the patient has marked difficulty in understanding the relationship between her substance use, addiction, mental health, or life problems and her impaired coping skills and level of functioning. For dimension 5, the patient relapsed following one month of sobriety. She has required two prior RTC admissions in the past two years. She reports significant urges to drink. She was started on naltrexone with a planned transition to Vivitrol. The patient was experiencing addiction symptoms such as drug craving. This situation posed an imminent danger of harm to self in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support was indicated to decrease addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors. For dimension 6, the patient was living alone and was socially isolated. She was working from home due to the pandemic, but she was unable to continue working for the past two weeks due to her alcohol usage. She has a conflicted relationship with her parents who drink. She has limited support system that consists of her sister. 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 dimensions for RTC services. Therefore, the RTC services were medically necessary for 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 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.