Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any of the residential treatment center (RTC)  (ASAM 3.1) level of care. Findings:  The physician reviewer found that this patient met 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 treated for alcohol withdrawal with a Librium taper. The patients withdrawal needs were safely managed in a Level 3.1 setting. For dimension 2, the patient has chronic ankle pain. The patients biomedical problems are stable and did not require medical or nurse monitoring. For dimension 3, the patient reported drinking and using heroin daily for the past three to five years. The records noted that the patient had symptoms of depression and lacked coping skills or knowledge of relapse triggers. He participated in group sessions. The patients mental status was stable enough to permit participation, and his symptoms and functional limitations, when considered in the context of his home environment, are sufficiently severe that he is assessed as not likely to maintain abstinence if treatment is provided in a nonresidential setting. For dimension 4, the patient admitted himself for treatment voluntarily as a result of worsening marital problems due to his addiction. He was able to acknowledge the negative consequences of his alcohol usage. The patient acknowledged the existence of an alcohol use problem, recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change, and was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5, the patient reported drinking 30 beers and using one gram of heroin/fentanyl daily for the past three to five years. He reported a one-year period of abstinence from opiates following an RTC stay but reported drinking alcohol during that time. He reported relapsing upon seeing an old friend and has been using opiates and alcohol. The patient demonstrates limited coping skills to address relapse triggers and urge and is in imminent danger of relapse with dangerous behavioral consequences in the absence of close 24-hour monitoring and structured treatment.For dimension 6, the patient lives with his wife and reports an abusive relationship. His friends and family include people who use substances and alcohol. He does not appear to have a sober social support network and is reported as having little knowledge of coping skills or relapse triggers. The patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities and has been living in an environment that is characterized by moderately increased risk of repetition of physical or emotional abuse that the patient is assessed as being unable to achieve or maintain recovery at a less intensive level of care.Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are 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. Accordingly, RTC (ASAM 3.1) level of care was and is medically necessary for the 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 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.