Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 RTC on 9/2/20 and completed diazepam taper. The patients withdrawal needs can be met in Level 3.1 setting. For dimension 2, the patient sustained a hematoma and required sutures on her scalp after falling backward the day before admission. There was no report of complications from this injury. She also has hypothyroidism. The patients biomedical problems are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has significant difficulties with major depression, anxiety, as well as some maladaptive personality traits of perfectionism and need for control. She was fearful of being able to tolerate difficult emotional states without using alcohol. She participated in groups. The patients mental status is assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients psychiatric condition is stable and she is assessed as having minimal problems in this area as evidenced by both of the following: the patients anxiety may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment and the patient is assessed as not posing a risk of harm to self or others. For dimension 4, the patient admitted herself for treatment after falling backwards while intoxicated and injuring herself. She has tried on several occasions to stop drinking and has been unable to do so despite recognizing negative consequences. She has expressed a desire to remain sober and has been able to identify negative consequences of her addiction. The patient acknowledges the existence of a substance use disorder. She recognizes specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been drinking two bottles of wine daily for several years. Her last period of sobriety was in 2017. She has undergone prior attempts at treatment and relapsed despite using anti-craving medications. She was fearful of having another relapse. She has continued to express that she is unable to maintain sobriety outside of the RTC due to difficulty coping with loneliness, lack of structure, and uncertainty. She was noted to have severe lack of these coping skills and was actively working on developing these by participating in groups and in individual therapy. The patient demonstrates limited coping skills to address relapse triggers and urges. She is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient lives alone and is unemployed. She is socially isolated and has not developed any structured way to spend her time upon discharge. The patient is 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 lacks social contacts and social network is characterized by significant social isolation and withdrawal leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting. Given these findings, the patient meets the six ASAM dimensions for RTC level of care services. Therefore, RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are 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.