Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for RTC services (equivalent to ASAM 3.1) provided by The Lakes Treatment Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient met and 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 treated with a Librium taper for alcohol withdrawal earlier in his stay. The patients withdrawal needs were safely managed in a Level 3.1 setting. For dimension 2, the patient was treated for dermatitis. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the records noted that the patient had a history of multiple arrests for driving under the influence (DUI) of alcohol. He was not suicidal or homicidal and participated in groups. The patients mental status was stable enough to permit participation and his psychiatric condition was stable as evidenced by both of the following: (1) the patient's anxiety and depression may be related to substance use problems or to a stable co-occurring emotional, behavioral, or cognitive condition, with imminent likelihood of relapse with dangerous consequences outside of a structured environment, and (2) the patient is assessed as not posing a risk to self or others.For dimension 4, the patient admitted himself for treatment voluntarily due to recognizing the effect of his substance use on his children after his girlfriends mother took his young children from him while he was under the influence. The records noted that he had recently been released from jail following a DUI charge. The patient was able to acknowledge negative consequences of his substance usage including relationship problems, parenting problems, loss of employment and financial problems. He acknowledged the existence of a substance use problem. He recognized specific negative consequences and dysfunctional behaviors and was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5, the patient reported drinking one pint of vodka and a dozen beers daily along with daily cocaine use for several years. This was his first attempt at treatment. The patient reported trying unsuccessfully to quit on his own by joining the Marines, however he relapsed and was discharged. He had a history of past and pending DUIs. He reported driving while intoxicated with his children in the car.  The records noted variable motivation to participate in group sessions. The patient needed staff support to maintain engagement in his recovery program while transitioning to life in the community.For dimension 6, the patient was homeless, unemployed, and living in a motel after spending two weeks in jail for a DUI charge. He did not have a sober social support network. The records noted conflict with his girlfriend over going to a sober living environment and noted that he was not able to return to living with his girlfriend and children at her parents house. The patient was able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities, but continued exposure to the patient's work or living environment made recovery unlikely, and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of the 24-hour supportive environment.Given these findings, the patient met and meets the six ASAM criteria for RTC services (equivalent to ASAM 3.1) provided by The Lakes Treatment Center. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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. Accordingly, the RTC services (equivalent to ASAM 3.1), provided by The Lakes Treatment Center, 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 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.