Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met 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 patients withdrawal needs could have been met in Level 3.5 setting. As of 8/2/20, the patient still experienced mild to moderate withdrawal symptoms of agitation, anxiety, and diaphoresis. He was monitored for withdrawal but declined treatment with benzodiazepines. For dimension 2, the patient has hypertension. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has diagnoses of major depressive disorder and he was in grief after his mother passed. He was noted to have difficulty in managing the loss of his mother and the loss of his former girlfriend without resorting to alcohol use. He also was noted to have significant underlying anger and aggression, which he has used alcohol to manage. The patients mental status was 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. In addition, the patient had significant functional deficits which were likely to respond to staff interventions. These symptoms were sufficiently severe that the patient was not likely to maintain abstinence if treatment was provided in a non-residential setting. The functional deficits were of a pervasive nature, requiring treatment that is primarily habilitative in focus and did not require medical monitoring or management. These deficits included residual psychiatric symptoms and inadequate anger management skills.  For dimension 4, the patient agreed to an admission after binge drinking vodka such that he required a one-day medical admission prior to RTC admission. He has been drinking one pint of vodka daily for 30 years and during binge episodes he reportedly drinks one-half gallon of vodka. He was assessed as being in the contemplative stage of change. The patients perspective impaired his ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which would enable him to develop insight into the role he plays in his substance use and mental condition, and empower him to make behavioral changes which can only be delivered in a 24-hour milieu. For dimension 5, the patient has not experienced a consistent period of sobriety since 2012. He was treated in an IOP program in 2019 without subsequent sobriety. He drinks heavily on a daily basis and then has days of increased consumption when he is unable to cope with losses and stressors. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and was therefore not committed to treatment. His continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient is living in a rented room and his roommates regularly drink alcohol. His social network is composed of other drinkers. The patients  social network included regular users of alcohol such that recovery goals were assessed as unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM dimensions for RTC services. Therefore, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.