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 3.5 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 with a Librium taper. The patient has continued to complain of agitation, tremors, and irritability. The patients withdrawal needs can be safely managed in a Level 3.5 setting.For dimension 2, the patient has cirrhosis secondary to alcohol use, rheumatoid arthritis, obesity, and visual problems. Her medical conditions will worsen if she continues to drink alcohol. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient reports feeling depressed and anxious due to her medical conditions of cirrhosis and pain due to autoimmune arthritis. The patient endorses drinking up to 24 beers daily and combining it with Klonopin, which places her at risk of falls and accidental overdose. The patient has reported strong urges to drink while at the RTC. She indicated that she feels hopeless about being able to stop drinking. She has been calling her husband to request that he pick her up from the facility. She initially had inconsistent group participation, but this has improved with each day of treatment. The patients mental status is 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 psychiatric condition is stabilizing. However, despite her best efforts, the patient is unable to control her use of alcohol with attendant probability of attendant danger. The resulting level of dysfunction is so severe that it precludes the patients participation in a less structured and intensive level of care. For dimension 4, the patient admitted herself after her husband gave her an ultimatum to stop drinking and enter treatment due to her escalating level of alcohol intake. She has been drinking up to 24 beers daily since her relapse after three months of sobriety. She has been drinking heavily for 20 years and has been diagnosed with cirrhosis. Notes indicate that the patient is hopeless about changing and stopping her alcohol usage. She reportedly voiced that she feels ready to die anyway so she plans to continue drinking. The patients perspective impairs her ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable him to develop insight into the role he plays in her substance use and empower her to make behavioral changes which can only be delivered in a 24-hour milieu. For dimension 5, the patient has been drinking up to 24 beers daily since her relapse in October 2020. She also takes Klonopin while drinking alcohol. The patient was diagnosed with cirrhosis in January 2020. This is the patients second attempt at treatment. The patient was assessed as being in the precontemplative stage of change and as seeing herself as incapable of change due to her medical problems. The patient has expressed that she has no interest in changing her use of alcohol. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. Her continued substance use poses an imminent danger of harm to self in the absence of 24-hour monitoring and structured support. For dimension 6, the patient is married and unemployed. She lives with her husband who is requesting that she stop drinking. She is otherwise socially isolated and does not engage with friends, family, or a therapist. She reportedly stays at home and drinks all day. The patients social network is characterized by significant social isolation or withdrawal, such that recovery goals are assessed as inconsistently achievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC 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.