Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Dual Diagnosis Residential Treatment Center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.1 criteria for the Dual Diagnosis Residential Treatment Center (RTC) services at issue. ASAM criteria focus on six dimensions to determine the appropriate level of care.For dimension 1 - Acute Intoxication and/or Withdrawal Potential. The patient had post-acute withdrawal syndrome (PAWS) of insomnia, restlessness, and elevated blood pressure. He had completed a Librium taper and was taking clonidine as needed. Based on clinical findings, the patients withdrawal needs could be met in a Level 3.1 setting.For dimension 2 - Biomedical Conditions and Complications. Records indicate that the patient had hypothyroidism. The patients biomedical problems were therefore stable and did not require medical or nurse monitoring.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient was diagnosed with major depressive disorder and generalized anxiety disorder. He acknowledged low self-esteem from years of being verbally abused by his ex-wife. He was still interacting with her due to sharing custody of his children with her. He was using alcohol to cope with this stress. He was actively participating in groups. The patients mental status was sufficiently stable to permit participation in the therapies provided in the residential treatment center, and his symptoms and functional limitations (residual psychiatric symptoms and chronic addictive disorder) were sufficiently severe that he was assessed as not likely to maintain abstinence if treatment was provided in a nonresidential setting.For dimension 4 - Readiness to Change. The patient admitted himself voluntarily after leaving against medical advice from the facility three days prior and relapsing the following day. He was motivated to complete a longer program. He was assessed as being in the contemplative stage of change. The patient required a 24-hour structured milieu to promote treatment progress and recovery, because motivating interventions had failed in the past and such interventions were not likely to succeed in an outpatient setting.For dimension 5 - Relapse, Continued use, Continued Use, or Continued Problem Potential. The patient had been in a relapse with brief periods of sobriety in structured settings. He used alcohol in a maladaptive manner in order to cope with the stressors in his life. He had been unable to manage more than a few weeks of sobriety in an unstructured setting. The patient demonstrated limited coping skills to address his relapse triggers and urges, and he was in imminent danger of relapse with dangerous consequences and needed 24-hour structure to help him apply recovery and coping skills.For dimension 6 - Recovery Environment. The patient was living with his fiance and children in a sober environment. He reported having a social network that consisted of people who were regular users of alcohol. 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. The patient's social network also involved many friends who were regular users of alcohol leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting.Using the ASAM level 3.1 criteria worksheet, the patient met all six criteria for medical necessity and therefore qualified for ASAM Level 3.1 treatment. Accordingly, the Dual Diagnosis Residential Treatment Center (RTC) services at issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services at issue were medically necessary to treat the patient's 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.