Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for any or all of the residential treatment center (RTC) level of care services. Findings:  The physician reviewer found that (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 patient was managed for alcohol withdrawal and the records noted protracted withdrawal symptoms including anxiety, agitation, and insomnia. The patients withdrawal needs were safely managed in a 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 reported using alcohol to manage her severe anxiety, agitation, restlessness, and insomnia. She requested a change in her medication regimen due to not feeling emotionally stabilized. She reported anxiety about stepping down to a lower level of care due to an inability to cope with distress without alcohol. She received psychoeducation on coping skills. The patients mental status was stable enough to permit participation, and she had significant functional deficits, likely to respond to staff interventions, which when considered in the context of her home environment, were sufficiently severe that the patient was assessed as unlikely to maintain mental stability and/or abstinence in a non-residential setting.For dimension 4, the patient admitted herself voluntarily for treatment after falling on her face during a blackout. She reported drinking multiple bottles of vanilla extract daily and blacking out weekly. The records noted a lack any coping skills to prevent relapse. The patient required structured therapy and a 24-hour programmatic milieu because her perspective impaired her ability to make behavioral changes without repeated, structured, clinically directed motivational interventions to enable her to develop insight into the role she played in her substance use and empower her to make behavioral changes.For dimension 5, this was the patients 16th attempt at treatment. She had relapsed after five and a half years of sobriety and reported drinking 16 to 24 ounces of vanilla extract daily, experiencing several blackouts per week. She reported a decline in her ability to function due to her worsening alcohol use disorder. She continued experiencing a high level of anxiety and cravings to drink and requested to start naltrexone. The records noted that the patient did not have effective coping skills. The patient was experiencing addiction symptoms such as alcohol cravings that posed an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. For dimension 6, the patient was married and lived with her husband. She reported having recently moved and having lost her Alcoholics Anonymous group and being socially isolated due to the COVID-19 pandemic. The patient had a long history of addiction including heroin addiction. She had a five-and-a-half-year period of sobriety from alcohol until relapsing the previous year. She reported conflicts in her marriage and was unable to cope with anxiety, agitation, and insomnia without resorting to drinking. She required a significant amount of psychoeducation and counselling regarding coping skills, distress tolerance, and relapse prevention skills. The patient was unable to cope, for even limited periods of time, outside of 24-hour care and required staff monitoring to learn to cope with before being transferred safely to a less intensive setting.Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. 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. Accordingly, the RTC level of care services 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.