Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (ASAM 3.5) level of care provided and forward. Findings:  The physician reviewer found that Per the American Society of Addiction Medicine (ASAM) criteria, this patient met and meets Level 3.5 criteria for residential treatment center services provided and forward. 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 addiction and benzodiazepine withdrawal earlier in his treatment stay. The patients withdrawal needs could have been safely managed in a Level 3.5 setting.For dimension 2, the patient has a history of three grand mal seizures and has an outpatient appointment for a neurology consultation. The patients biomedical problems were and are stable. He does not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications.For dimension 3, the patient has been diagnosed with generalized anxiety disorder. The patient complains of severe panic attacks. He was noted to possibly be delusional with grandiose and paranoid delusions. The patient has been taking 12-20 Xanax on a daily basis for the past year and also drinks a pint to a fifth daily of alcohol. He has history of blackouts and seizures. The patient was noted to be impulsive and attempted to leave treatment when he could not watch a basketball game. He also threatened to have his friends shoot another resident after they left the facility in response to a disagreement. Based on these findings, the patient meets the requirements for this dimension.For dimension 4, the patient was admitted voluntarily for treatment but this was at the request of his parents. He had been drinking a pint to a fifth of liquor daily and combining this with 12-20 mg of Xanax daily. He was assessed as being in the pre-contemplative stage of change and blamed his parents and his social group for his relapse and his usage in general. Based on these findings, the patient did meet the requirements for this dimension.For dimension 5, this is the patients second attempt at treatment. The patient admitted himself due to his parents requesting that he do so. He has been drinking one pint to a fifth of liquor daily and taking 12-20 mg of Xanax for the past year and has history of blackouts and seizures. The patient blames his friends and his parents for his relapse a month ago. He reports that his parents are relapse triggers for him as they are `old.` The patient is unemployed due to his substance usage. He has a troubled relationship with his parents due to his substance usage, has been kicked out of their home, and is living in his car. He has developed legal problems. Based on these findings, the patient did meet the requirements for this dimension.For dimension 6, the patient is homeless and living in his car after being kicked out of his parents home. The patient is unemployed due to his substance usage. The patient reports that he is a rapper and that everyone in his social group uses drugs as part of his lifestyle. He does not have a sober support system. Based on these findings, the patient did meet the requirements for this dimension.The ASAM criteria requires adult patients to meet all six dimensions to support residential treatment center services. This patient did meet all the dimensions for Level 3.5 residential treatment center criteria. Moreover, the services were and are in accordance with the generally accepted standards of mental health and substance use disorder care. The services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician or other health care provider. Given these findings, the residential treatment center (ASAM 3.5) level of care provided and forward were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue 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 psychiatry 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.