Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services (ASAM 3.5). Per medical 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 patient was prescribed naltrexone for management of alcohol withdrawal. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient did not have biomedical problems and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had diagnoses of major depressive disorder and anxiety disorder.  They reported drinking heavily daily and using alcohol to manage depression and anxiety. They were unable to control their drinking, with a history of blackouts. They demonstrated a repeated inability to control their impulses to use alcohol or to engage in antisocial behavior patterns and was in imminent danger of relapse with attendant likelihood of harm to self, with a resulting level of dysfunction of such severity that it precluded participation in a less structured and intensive level of care.For dimension 4, the patient was admitted to the RTC after medical treatment for alcohol poisoning after drinking to a state of blackout. They reported drinking to the point of blackouts daily and of being unable to cope with negative emotions without the use of alcohol. The patient was willing to receive treatment but had limited insight into severity of their alcohol use. Due to the intensity and chronicity of the patients addictive disorder, they had limited insight and little awareness of the need for continuing care.For dimension 5, this was the patients first RTC attempt. Their grades had declined drastically due to daily substance use. The patient did not recognize relapse triggers and lacks insight into the benefits of continuing care and was therefore not committed to treatment. Their 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 did not have a sober peer group since starting to use substances. The patients social network involved regular users of alcohol and drugs such that the individuals 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. The services at issue were in accordance with the generally accepted standards of mental health and substance use disorder care. The services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. Additionally, the services at issue were 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. Therefore, RTC services (ASAM 3.5) were medically necessary for the 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 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.