Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services (ASAM Level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet 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 was assessed for alcohol withdrawal earlier in his treatment stay and did not have significant withdrawal. The patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient has hyperlipidemia. The patients biomedical problems, if any, 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 is noted as being diagnosed with generalized anxiety disorder. The patient has not been suicidal or homicidal. He does not have history of overdose or suicide attempts. He has had minor bouts of anger control problems when arguing with his wife. The provider charted that the patient has participated in groups. The patients mental status has been 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. However, the records do not demonstrate that the patient meets any of the other requirements for this dimension. There is a lack of documentation that the patient is unable to control his use of alcohol and drugs with attendant probability of imminent danger, demonstrates repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrates antisocial behavior patterns, or has significant functional deficits, which are likely to respond to staff interventions...of pervasive nature requiring treatment that is primarily habilitative in focus. There is a lack of report of concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 4, the patient admitted himself for treatment voluntarily after having another episode of binge drinking. The patient has been able to admit that he has an alcohol use disorder, and he has participated in treatment. He has expressed interest in changing due to negative effects on his well-being and his marriage. The records do not support that the patient requires 24-hour programmatic milieu to sustain motivation. The patient has shown insight and awareness of the need for continuing care or has marked difficulty in understanding the relationship between his substance use, mental health, or life problems and her impaired coping skills and level of functioning or demonstrates passive or active opposition to addressing the severity of his addiction problem. Moreover, there is a lack of support that the patient requires structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care, perspective impairs his ability to make behavior changes without repeated, structured motivational interventions, expresses little to no interest in changing, or attributes his alcohol, drug or mental health problem to other persons or external events. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 5, the patient  drinks in a binge type manner and drinks one quart of vodka or one bottle of wine during his binges. He recognized the need for treatment and continuing care. He has previously been on naltrexone but did not find it beneficial. The patient denies suicidal and homicidal ideation. On review of the records, the patient does not lack insight into benefits of continuing care, or unable to control use of alcohol or drugs with attendant probability of harm to self or others. The patient is not reportedly experiencing craving...with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. There is a lack of support that the patient is in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation or continuing to use alcohol or drugs. Based on these findings, the patient does not meet the requirements for this dimension.For dimension 6, the patient is living with his wife who rarely drinks and is supportive of his recovery. He works as a web designer. He does have support through AA and other professional supports. The available records do not report that the patient is living in an environment that is characterized by a moderately high risk of neglect or emotional abuse or endemic substance use, that the patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as unachievable at a less intensive level of care, or that the patients social network is characterized by significant social isolation or withdrawal such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. The records do not support that the patients social network involves living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs, or that the patient has been unable to cope, for even limited periods of time, outside of 24-hour care. Based on these findings, the patient does not meet the requirements for this dimension.The ASAM guidelines require adult patients to meet all six dimensions to support Level 3.5 RTC services. This patient does not meet Level 3.5 RTC criteria for dimension 3, 4, 5, or 6. Moreover, the RTC services are not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration. Given these findings, the RTC services (ASAM Level 3.5) were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine and is actively practicing.