Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.1 criteria for the Residential Treatment Center (RTC) services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient was admitted to residential treatment center care and underwent withdrawal management with diazepam for alcohol and sedative hypnotic withdrawal. Based on clinical findings, the patients withdrawal needs could be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient did not have any ongoing medical problems. The patients biomedical problems were therefore stable and did not require medical or nurse monitoring.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient had been drinking 20 drinks daily and using Xanax every night to sleep. He was married with two young children. He was working from home and he drank while he was working. The patients wife indicated that he had been verbally abusive to her and that he had driven the children while intoxicated. The patient was not able to maintain sobriety in his home environment for more than two to three days at a time. He participated in groups. The patient met the subcriteria of having mental status that was stable enough to permit participation. At the same time, the patient's symptoms and functional limitations, when considered in the context of his home environment, were sufficiently severe that he was assessed as not likely to maintain abstinence if treatment was provided in a nonresidential setting. The patients functional limitations included chronic addictive disorder and inadequate anger management skills.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily after he was unable to make changes in his drinking and Xanax usage with outpatient therapy and groups. He was described as being in the contemplative stage of change. The patients parents gave him an ultimatum that he had to enter formal treatment after he relapsed after 20 days of abstinence. He reported that he was not confident in his ability to remain abstinent if he did not receive residential treatment. He was able to identify specific negative consequences of his alcohol usage including marital problems, relationship problems, occupational problems and financial problems. The patient acknowledged the existence of his substance use problem. He also recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. Records indicate that the patient was also sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5 - Relapse, Continued use, or Continued Problem Potential. The patient had been drinking 20 drinks daily on most days of the week and had been drinking regularly since college. His usage had steadily increased, especially over the previous three years. He had also been taking Xanax to help him sleep and had increased this medication to 2 mg daily while he was trying to reduce his drinking. He had attempted to quit on his own and with outpatient treatment, but he was unable to have more than two to three days of sobriety at a time. The patient therefore demonstrated limited coping skills to address relapse triggers and urges, and he was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to help him apply recovery and coping skills.For dimension 6 - Recovery Environment. The patient was living with his wife and two small children, and he was drinking at home while working. The patients wife reported that he was angry and was frequently yelling at her and the children while intoxicated. He also drove the children around while intoxicated. The patient therefore met the subcriteria of being 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 made recovery unlikely, and the patient had insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Using the ASAM level 3.1 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.1 treatment. Accordingly, the residential treatment center services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's 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.