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) services provided at The Lakes Treatment Center, using the Level 3.5 guideline from the American Society of Addiction Medicine (ASAM) Criteria, 3rd Edition. Per 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. 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 had diagnoses of generalized anxiety disorder and depression and reported using alcohol daily for the past five to seven years. She was on parole following incarceration and had a pending court date. She had a history of three prior treatment attempts and relapsed following a ten-month incarceration. The patients mental status was stable enough to permit participation. She demonstrated a repeated inability to control her impulses to use alcohol and engage in antisocial behavior, and she was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient did not remember being admitted to the RTC by her family members. She reported drinking a fifth of vodka daily. She had a history of three RTC stays and a ten-month incarceration, relapsing within 30 days of release. 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. For dimension 5, this was the patients fourth RTC attempt. She reported drinking a fifth of vodka daily for the past five to seven years. She reported drinking to the point of blackouts and that she had started drinking daily as a teenager. She lacked housing due to a crisis involving significant legal problems and was on parole. The patient was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences, as a result of a crisis situation. For dimension 6, the patient was divorced and had been living with her 83-year-old father. However, she had been charged with elder abuse prior to her admission to the RTC and reported being unsure if she would be allowed to return to the home, or if she would be sent back to jail. She had significant relationship difficulties with her children and was not allowed to attend her daughter's wedding nor see her grandchildren. She reported drinking daily when not in a RTC or incarcerated and had been unable to achieve more than 30 days of sobriety upon release. 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 problems 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 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, the RTC services provided at The Lakes Treatment Center, using the Level 3.5 guideline from the ASAM Criteria, 3rd Edition, were and are medically necessary for 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.