Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 drinking one quart of whiskey daily for the past year and was treated with a Librium taper. He continued to have mild to moderate withdrawal symptoms as of 10/15/20. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient is status post three cerebrovascular accidents in 2019 with left-sided weakness. The patient has a history of hypertension, hyperlipidemia, and gastritis. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has been diagnosed with major depressive disorder and was suicidal upon admission. He expressed a plan to overdose, but he had no means of carrying this out in the RTC. The provider documented that the patient experiences frequent suicidal ideation that is exacerbated by drinking. The patient has two prior suicide attempts and was admitted for suicidal ideation on a 5150 hold prior to admission. He endorsed multiple symptoms of depression including hopelessness, anhedonia, depressed mood, and poor sleep. The patients mental status is assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has significant functional deficits which are likely to respond to staff interventions. These symptoms and deficits are sufficiently severe that the patient is not likely to maintain abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature, requiring treatment that is primarily habilitative in focus and do not require medical monitoring or management. For this patient, they include residual psychiatric symptoms. For dimension 4, the patient was admitted two days after discharge from an inpatient psychiatric facility after being admitted on a 5150 hold for suicidal ideation with plan to overdose. He also attempted suicide by overdose two months prior to this admission. He has been extremely depressed with frequent episodes of suicidal ideation. His alcohol usage has worsened his depressive disorder and places him at higher risk for suicidality. He has been using alcohol to cope with his difficulty processing the loss of his physical functioning from the cerebrovascular accident and resultant job loss. Despite experiencing serious consequences of the addictive disorder, the patient has marked difficulty in understanding the relationship between his substance use, mental health, or life problems and his impaired coping skills and level of functioning, often blaming others for his addiction problems. For dimension 5, the patient has been drinking heavily for 30 years and most recently relapsed after he had three strokes in August 2019. He has been unable to stop drinking on his own due to withdrawal symptoms. He was unaware of relapse triggers. He was experiencing a high level of cravings to drink alcohol but was unable to tolerate oral naltrexone. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care. His continued substance use poses an imminent danger of harm to self in the absence of 24-hour monitoring and structured support. For dimension 6, the patient is homeless and living in a camper. He lives alone, is disabled, and is socially isolated. He has been experiencing frequent suicidal ideation with severe depression and continues to have high level of cravings to use alcohol. He has been unable to cope with his physical disabilities without resorting to drinking. The patient has been unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with dimension 6 problems before being transferred to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC level of care services were and are medically necessary for 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 ** 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.