Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the residential treatment center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.1 nor 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 did not require withdrawal management. The patients withdrawal needs were safely managed in a Level 3.1 setting. For dimension 2, the patient had a history of diabetes, asthma, arthritis, and celiac disease. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient was diagnosed with bipolar disorder, depression, general anxiety disorder, and post-traumatic stress disorder. She reported passive suicidal ideation and thinking of overdosing before admission to the RTC. While at the RTC, the patient was not suicidal, homicidal, or psychotic, and underwent a psychiatric evaluation and adjustment of her psychotropic medication. She participated in group sessions. The patients mental status was stable enough to permit participation, but she was not in imminent likelihood of relapse with dangerous consequences outside of a structured environment, and her co-occurring psychiatric, emotional, behavioral, or cognitive conditions were being addressed concurrently through appropriate psychiatric services.For dimension 4, the patient admitted herself for treatment of her alcohol use disorder and comorbid psychiatric illness. She was able to identify negative consequences from usage. The patient recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change. She was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.For dimension 5, the patient relapsed after three years of sobriety. The patient was motivated, gaining insight, and working on coping skills. The patient was not in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences, unable to consistently address both addiction and mental disorder and thus at risk of relapse in a less structured level of care, or in need of staff support to maintain engagement in her recovery program while transitioning to life in the community. This criterion was not met. For dimension 6, the patient lived with her husband and son, and had previous contact with Alcoholics Anonymous in her community. 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, but was not living in an environment characterized by repetition of physical or emotional abuse such that she was assessed as being unable to achieve or maintain recovery at a less intensive level of care, lacking in social contacts with a social network characterized by significant social isolation and withdrawal, living in an environment highly invested in alcohol, lacking sufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment, nor in danger of victimization. This criterion was not met. Given these findings, the patient did not meet the six ASAM criteria for RTC services. In this patients case, RTC level of care was not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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. Accordingly, the RTC services provided were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.