Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for (1) all or any of the requested residential treatment center (RTC) services, and (2) a 60 day RTC program. Per American Society of Addiction Medicine (ASAM) criteria, this patient met 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 managed for withdrawal symptoms with a diazepam taper. She reported symptoms of withdrawal and high cravings at ten out of ten.  The patients withdrawal needs were safely managed in a level 3.1 setting. For dimension 2, the patient had possible hypertension and a history of elevated liver function tests. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported symptoms of depression and anxiety. She was living with an abusive partner and was in the process of leaving this relationship. She had a history of childhood trauma. She participated in group sessions. The patients mental status was stable enough to permit participation and her symptoms and functional limitations, when considered in the context of her home environment, are sufficiently severe that she was assessed as not likely to maintain mental stability and abstinence in a nonresidential setting.For dimension 4, the patient voluntarily admitted herself for treatment because she was unable to stop drinking and manage her withdrawal symptoms on her own. She recognized an increase in the amount of her alcohol consumption to twelve units daily. The patient recognized specific negative consequences and dysfunctional behaviors and was sufficiently ready to change and cooperative enough to respond to treatment in a level 3.1 setting.For dimension 5, the patient reported drinking regularly since age 16, and drinking up to twelve units of alcohol daily since age 21. She reported that her longest period of sobriety was three months five years ago.  The records noted the patient had poor insight into relapse triggers, did not have coping skills of managing her urges to drink, and was ambivalent regarding a need to change. She was trying to leave her current relationship, which she characterized as abusive. Despite understanding her addiction and mental disorder, the patient was unable to consistently address both and was at high-risk of relapse in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient was living with an abusive partner that she was in process of leaving. She did not have a sober network. She had previously worked as a bartender and was unemployed due to the pandemic. The patient was living in an environment characterized by a repetition of physical or emotional abuse 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. 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. Therefore, RTC services were medically necessary for the treatment of this patient. With regard to the 60-day RTC program, ASAM guidelines state, All decisions about when to end services, change services, and when to continue services are based on the progress the patient is making. Further, the ASAM criteria do not support any treatment graduation dates, or completion dates that can be assigned before treatment has even begun. The length of treatment depends upon the progress made, in clearly defined and agreed-upon goals, rather than a result of a programs preset structure. In this patients case, a 60-day RTC program is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested service is not clinically appropriate in terms of type, frequency, extent, site, and duration. The requested service is 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. Therefore, a 60-day RTC program from is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are partially medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.