Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested reimbursement for residential treatment center (RTC) services for substance use disorder, specifically ASAM Level 3.5. Per the American Society of Addiction Medicine (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 at another facility. The records indicate that the patients withdrawal needs could have been safely managed in a Level 3.5 setting. For dimension 2, the patient is noted to have comorbid chronic obstructive pulmonary disease (COPD) and asthma. 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 generalized anxiety disorder and severe major depressive disorder. The records indicate that the patient was severely depressed with impaired ability to perform activities of daily living and difficulty concentrating. One day after admission, the patients stepson died from an overdose and the patient reported only knowing how to cope with alcohol. The patient endorsed drinking one pint of vodka on a daily basis for decades, driving while intoxicated, and experiencing blackouts. The patients mental status permitted participation and the patients psychiatric condition was stabilizing. However, despite best efforts, the patient was unable to control alcohol use with attendant probability of attendant danger. The resulting level of dysfunction was so severe that it precluded the patients participation in a less structured and intensive level of care. For dimension 4, the patient was admitted voluntarily for treatment after being asked to leave the home due to alcohol use. The patient also lost a job due to alcohol use in February 22. The patient has been drinking on a daily basis and has been drinking one pint of vodka daily for decades. This patient was noted to have poor insight into alcohol usage and to have limited readiness to change. The patient was ruminating on the past and had difficulty concentrating on steps needed to remain sober in the future. Because of the intensity and chronicity of the addictive disorder, there is limited insight and little awareness of the need for continuing care or the existence of substance use and need for treatment, and thus has limited readiness to change. For dimension 5, this patient underwent at least two prior attempts at treatment with RTC admissions. The patients longest period of sobriety has been 90 days. The patient was not able to identify relapse triggers and was noted to have minimal ability to cope with significant stressors. The patient was also grieving the death of stepson during this RTC admission. The patient expressed doubts about the ability to remain sober for longer than 90 days. The patient did not recognize relapse triggers and lacked insight into the benefits of continuing care and was therefore not committed to treatment. The patient continued substance use posed an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient was unemployed due to alcohol use disorder. The patient was staying in motels after being kicked out of the house by the spouse due to drinking. The patient was socially isolated except for the spouse, and was noted to have significant social anxiety that limited participation during treatment. The patients social network was characterized by significant social isolation or withdrawal, such that recovery goals were assessed as unachievable at a less intensive level of care. Based on these findings, the patient meets the six ASAM dimensions to support 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 were not primarily for the convenience of the patient or provider. All told, the RTC services for substance use disorder, specifically ASAM Level 3.5 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.