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 3.1 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 at a detoxification center for 10 days prior to admission to the RTC. She has demonstrated withdrawal symptoms including anxiety and cravings. The patients withdrawal needs can be met in Level 3.1 setting.For dimension 2, the patient does not have active medical problems. The patients biomedical problems, if any, are stable and do not require medical or nurse monitoring. For dimension 3, the patient has had recent periods of passive suicidal ideation and ongoing severe anxiety for which she was started on gabapentin. The patients mental status is 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 psychiatric condition is stable and she is assessed as having minimal problems in this area as evidenced by both of the following: (1) anxiety that may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment and (2) the patient is assessed as not posing a risk of harm to herself or others. For dimension 4, the patient admitted herself to RTC treatment voluntarily after undergoing a 10-day detoxification. She was assessed as being in the contemplative stage of change and identified negative consequences of her alcohol usage. The patient recognizes specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient has been drinking heavily on a daily basis for the past nine months without any periods of sobriety. She has attempted to quit on her own but been unable to do so due to withdrawal symptoms. She expressed not understanding why she drinks nor having insight into relapse triggers. The patient demonstrates limited coping skills to address relapse triggers and urges. She is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient has unstable housing as she is no longer living in her prior residence with roommates. She has been staying with her boyfriend who drinks alcohol. She lost her job due to her alcohol use disorder. The patient is able to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patients living environment makes recovery unlikely, and the patient has in sufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC services were and are medically necessary for treatment of 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 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.