Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) 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 underwent withdrawal management for alcohol withdrawal. The patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient does not have any medical problems. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD). She has been using large amounts of alcohol and cannabis to manage her anxiety and panic. She has had difficulty tolerating antidepressants for MDD and GAD as she developed suicidal ideation on Lexapro recently. She had difficulty fully participating in groups due to social anxiety and panic attacks. She also was anxious about returning to her home environment due to prior trauma with her family of origin. She required a lot of psychoeducation from staff regarding abuse and trauma. The patients mental status was 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 patient has significant functional deficits, which were likely to respond to staff interventions. These symptoms and deficits, when considered in the context of her home environment, were sufficiently severe that the patient was not likely to maintain mental stability and/or abstinence if treatment was provided in a non-residential setting. The functional deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus; they do not require medical monitoring or management. They may include residual psychiatric symptoms, chronic addictive disorder, and the sequelae of physical, sexual, or emotional trauma. For dimension 4, the patient was voluntarily admitted to RTC after she was unable to stop drinking while participating in a partial hospitalization program (PHP). The patient continued to drink one to two bottles of wine daily and consume cannabis edibles daily. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery because motivational interventions have not succeeded at less intensive levels of care and such interventions were assessed as not likely to succeed at a less intensive level of care. For dimension 5, this is the patients second attempt at treatment after she was unsuccessful at the PHP level of care. She continued to drink one to two bottles of wine daily despite being in the PHP and she indicated that she was unable to manage her anxiety without drinking. The patient experienced a decline in her ability to function and work due to her worsening psychiatric status and alcohol use disorder. She was started on Lexapro as an outpatient, but this was discontinued due to the development of suicidal ideation. Despite recent, active, participation in treatment at a less intensive level of care, the patient continues to use alcohol or other drugs, or to deteriorate psychiatrically, with imminent serious consequences, and is at high risk of continued substance use or mental deterioration in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient is single and lives in an apartment in the same building as many family members, including her mother. She is reportedly a caregiver for her mother. She has significant history of childhood abuse from within the family of origin that is unresolved. She has been unable to cope with the anxiety and panic from unresolved trauma without resorting to drinking. She required a significant amount of psychoeducation and counseling regarding these issues and was planned to discharge to an alternative living environment rather than return to being in close proximity to her family. The patient was unable to cope, for even limited periods of time, outside of 24-hour care. She needed staff monitoring to learn to cope with Dimension 6 problems before being transferred safely to a less intensive setting. Based on these findings, this patient meets all six ASAM dimensions for RTC services. Moreover, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the RTC services were medically necessary for 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 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.