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 the RTC after a four-day detoxification at another facility. She has withdrawal symptoms of insomnia, anxiety, headache, tremors, and restlessness. The patients withdrawal needs can be met in Level 3.1 setting. For dimension 2, the patient has a diagnosis of hypertension. The patients biomedical problems are stable and do not require medical or nurse monitoring. For dimension 3, the patient has comorbid depression and anxiety. She has multiple symptoms of depression including anhedonia, insomnia, poor appetite, and passive suicidal ideation. She has lost her marriage and her employment within the past year and has trouble coping with these losses without drinking alcohol. She 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. The patients symptoms and functional limitations, when considered in the context of her home environment, are sufficiently severe that she is assessed as not likely to maintain mental stability and abstinence if treatment is provided in a nonresidential setting. Functional limitations may include residual psychiatric symptoms. For dimension 4, the patient admitted herself for treatment of her alcohol use disorder since she was not able to stop drinking on her own after RTC treatment and relapse in late 2020. The patient endorsed drinking six or more mini bottles of vodka daily. She is able to identify negative consequences of her alcohol usage including occupational problems, declining health, and relationship problems. The patient acknowledges the existence of a psychiatric condition and substance use problem. 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 reported drinking six or more mini bottles of vodka on a daily basis for the past 10 years. She relapsed immediately after a 38 day RTC admission in late 2020. This is the patients second attempt at treatment other than Alcoholics Anonymous. She did not believe that she had any relapse triggers. She has experienced blackouts with an injury within the past year, but she continues to engage in high-risk behaviors related to alcohol use. The patient demonstrates limited coping skills to address relapse triggers and urges. She is in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient lives with her adult son and she has troubled relationships with her other adult children. She was recently fired from her job due to drinking alcohol while at work. She went through a divorce in August 2020 and she is socially isolated. She has been unable to cope with her divorce, unemployment, and resultant financial stress without resorting to alcohol. 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. Continued exposure to the patients living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC level of care 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.