Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) level of care services. 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 reported that he was drinking 150 ounces of malt liquor daily and taking up to 8 mg of Xanax on a daily basis up until the day of admission. He was treated with a Librium taper. This patient demonstrated withdrawal symptoms including anxiety, irritability, tremors, and diaphoresis. He continued to have Clinical Institute Withdrawal Assessment (CIWA) scores up to 13. The patient was in withdrawal and his withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the continued alcohol use placed the patients health at significant risk. The patient has medical conditions that include hypertension, hepatitis C, and a fractured hip last year. He complained of ongoing arthritic pain that he felt was a distraction to his recovery efforts. Thus, the patient had a biomedical condition that was not severe enough to warrant inpatient treatment but was sufficient to distract from his treatment of recovery efforts. For dimension 3, the patients mental status was sufficiently stable to permit participation. He endorsed significant depression and inability to cope after his mother passed away in January 2020 that resulted in him relapsing on alcohol. The patient is married and was arrested on domestic violence charges prior to admission, which resulted in his becoming homeless. The patient has demonstrated antisocial behavior that has led to criminal justice issues. The patient was unable to control his use of alcohol, substances and antisocial behaviors, with attendant probability of imminent danger. The resulting level of dysfunction was so severe that it precluded the patients participation in a less intensive level of care. For dimension 4, the patients wife brought the patient to treatment after he was placed on house arrest with an ankle monitor. The provider assessed the patient as being in the precontemplative stage of change. The patient met this requirement since despite experiencing serious consequences of effects of the addictive disorder the patient had marked difficulty in understanding the relationship between his substance use and his impaired coping skills and level of functioning. For dimension 5, the patient has been drinking alcohol and using substances for decades. Prior treatment included two RTC admissions. He most recently relapsed on alcohol after his mother passed away in January 2020. The patient continued to experience insomnia, anxiety and irritability. He was unable to tolerate several medications to manage these symptoms. During the most recent relapse, he was arrested on domestic violence charges while intoxicated. Overall, the patient was experiencing psychiatric or addiction symptoms such as drug cravings and insufficient ability to postpone immediate gratification and other drug seeking behaviors. The continued substance use posed an imminent danger of harm to the patient or others in the absence of 24-hour monitoring. For dimension 6, the patient became homeless following an altercation with his wife and he required an ankle monitor. He has a history of multiple incarcerations and his social support network consisted of other regular users of alcohol and substances. Thus, the patients social network included regular users of alcohol and other drugs such that the patients recovery goals were assessed as unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for treatment at the RTC level of care. For these reasons, 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.