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 the 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 was treated for alcohol withdrawal in the emergency department and discharged on Librium to obtain negative Covid-19 results prior to admission to the RTC. The patients withdrawal needs could be met in Level 3.1 setting. For dimension 2, the patient had chronic pain controlled on tramadol. The patients biomedical problems were stable and did not require medical or nurse monitoring.  For dimension 3, the patient was diagnosed with depression, panic disorder, and anxiety. She complained of significant anxiety and panic that led to urges to drink alcohol. She demonstrated a low appetite with weight loss. The patient actively participated in groups. The patients mental status was assessed as sufficiently stable to allow the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients symptoms and functional limitations including residual psychiatric symptoms and chronic addictive disorder were sufficiently severe that she was assessed as not likely to maintain abstinence if treatment is provided in a nonresidential setting. For dimension 4, the patient voluntarily admitted herself to RTC after having two months of continuous binge drinking such that she lost her job and became homeless. Her provider reported that outpatient motivational treatments had previously failed in the outpatient setting. The patient required a 24-hour structured milieu to promote treatment progress and recovery, because motivating interventions have failed in the past and such interventions were assessed as not likely to succeed in an outpatient setting. For dimension 5, the patient drank heavily on a daily basis since 2016 with three weeks as her longest period of sobriety. She has made several attempts to quit since 2015 with little improvement. She uses alcohol in a maladaptive manner in order to cope with anxiety and history of trauma. The patient demonstrated limited coping skills to address relapse triggers and urges. She was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient was unemployed, homeless, and socially isolated. She was unable to work due to her alcohol use disorder. Her family of origin are former addicts. 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. Moreover, the patient lacked social contacts, leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, 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.