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 e American Society of Addiction Medicine (ASAM) criteria, 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 had severe alcohol withdrawal that was managed in the inpatient setting. He reportedly demonstrated withdrawal symptoms and he was started on Campral. The patients withdrawal needs could be met in Level 3.1 setting. For dimension 2, the patient has alcoholic hepatitis and a history of alcoholic pancreatitis and hepatorenal syndrome He was medically stable prior to transfer to the rehabilitation. The patients biomedical problems were stable and did not require medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 3, the patient did not have a reported psychiatric diagnosis. Per ASAM, the patient may not have any significant problems in this dimension. For dimension 4, the patient voluntarily admitted himself due to the severity of his alcohol use. He was he was drinking one liter of vodka daily and experienced significant medical sequelae of his alcohol usage. He recognized that these problems were due to his alcohol addiction, he participated in groups, and he requested a discharge plan that would maximize his chances for recovery. The patient acknowledged the existence of a substance use problem. He recognized specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has a severe alcohol use disorder with a high consumption of alcohol on a daily basis. The records document that the patient underwent severe alcohol withdrawal with delirium and seizures. He is unemployed due to his alcohol usage and he lacks structure in his life. The patient needed staff support to maintain engagement in his recovery program while transitioning to life in the community. For dimension 6, the patient was unemployed and living in a camper on mothers driveway. His social network is composed of alcohol users. He was anxious about his return home due to the lack of a sober support network. The patient was able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment made recovery unlikely and the patient had insufficient skills to maintain adequate level of functioning outside of a 24-hour supportive environment. These findings support that the patient meets the six ASAM dimensions for RTC services. Accordingly, the RTC level of care 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.