Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any or all of residential treatment center (RTC) (ASAM 3.5) level of care. Findings:  The physician reviewer found that Per American Society of Addiction Medicine (ASAM) criteria, this patient did 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 treated for alcohol withdrawal earlier in the RTC stay. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient did not have significant medical problems. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had a history of trauma and anxiety. He was not suicidal or homicidal, and did not have a history of overdoses, suicide attempts, or aggressive behavior towards others. He participated in group sessions. The patients mental status was stable enough to permit participation, but the records did not indicate that he was unable to control his use of alcohol or was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrated antisocial behavior patterns, had significant functional deficits of a pervasive nature requiring treatment that is primarily habilitative in focus that were likely to respond to staff interventions, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provided opportunities to promote continuous boundary setting interventions. This criterion was not met.For dimension 4, the patient admitted himself for treatment voluntarily due to relationship and occupational problems resulting from his alcohol use. He was able to admit that he had an alcohol use disorder, participated in treatment, and expressed interest in changing his alcohol usage. The records did not indicate that the patient had limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between substance use, mental health, or life problems and her impaired coping skills and level of functioning, demonstrated passive or active opposition to addressing the severity of her addiction problem, or required structured therapy and a 24 hour programmatic milieu because motivational interventions had not succeeded at less intensive levels of care. The patient did not have a perspective that impaired his ability to make behavior changes without repeated, structured motivational interventions, express little to no interest in changing, or attribute his alcohol, drug or mental health problem to other persons or external events. This criterion was not met. For dimension 5, the patient reported drinking up to three quarters to a fifth of vodka daily. He recognized the need for treatment and continuing care. The patient did not have a history of suicidal or homicidal ideation, suicide attempts, or aggression. The records did not indicate that the patient lacked insight into benefits of continuing care and was therefore not committed to treatment, was unable to control use of alcohol or experiencing cravings with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, continued to use alcohol despite recent active participation in treatment at a less intensive level of care, or demonstrated a lifetime history of repeated incarceration. This criterion was not met.  For dimension 6, the patient was living with a roommate who used alcohol and drugs and worked in the cannabis industry. The patient's social network involved living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs. Given these findings, the patient did not meet the six ASAM criteria for RTC services. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. Accordingly, RTC (ASAM 3.5) level of care was 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 sub-specialty 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.