Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for RTC services (ASAM 3.5) at The Lakes Treatment Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient met 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 environmentFor dimension 1, the patient underwent management for alcohol withdrawal earlier in his treatment stay. The patients withdrawal needs were and are safely managed in a Level 3.5 setting. For dimension 2, the patient does not have medical problems and does not require 24-hour medical or nurse monitoring. For dimension 3, the patient has a diagnosis of generalized anxiety disorder and reported using alcohol, more recently in combination with up to 2 mg of Xanax, to manage his anxiety. He reported a history of significant blackouts lasting up to three days. He was unable to control his impulses to use alcohol outside of the residential setting and reported an episode of inebriation while on the job to the point of passing out in a golf cart. He reported continued symptoms of anxiety exacerbated by withdrawal, resulting in urges to use alcohol. The patients mental status was stable enough to permit participation, he demonstrated an inability to control his impulses to use alcohol with attendant likelihood of harm to self, resulting in a level of dysfunction of such severity that it precludes participation in a less structured and intensive level of care.For dimension 4, the patient was admitted voluntarily for treatment. He reported drinking a fifth of liquor daily for over ten years. He reported participating in one week of intensive outpatient program (IOP) after discharge from an RTC before dropping out of the program and relapsing. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because motivational interventions have not succeeded at less intensive levels of care. For dimension 5, the patient has a history of multiple attempts at treatment. He reported drinking a fifth of liquor daily, with a history of significant blackouts lasting up to three days. He reported using alcohol and Xanax to manage his significant anxiety. He reported ongoing urges to drink and was to be started on naltrexone at the RTC. The patient is experiencing addiction symptoms such as drug craving, posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. The introduction of psychopharmacologic support is indicated to decrease addictive symptoms, such as cravings, that will enable the patient to delay immediate gratification and reinforce positive recovery behaviors.For dimension 6, the patient was living with his brother and with his girlfriend who uses heroin on a regular basis. He reported using heroin the day before his RTC admission. He does not have a sober support system. The patients social network includes regular users of drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, 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. Accordingly, the RTC services (ASAM 3.5) at The Lakes Treatment Center 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 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.