Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 
The patient is a 52-year-old female who was initially admitted on 4/07/21 for treatment of alcohol use disorder.  The patient has requested reimbursement for residential treatment services (ASAM 3.5) provided from 4/13/21 through 5/05/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for residential treatment services from 4/13/21 through 5/05/21. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. For dimension 1, the patient was treated for alcohol withdrawal earlier in her course of treatment. Based on clinical findings, the patientas withdrawal needs could have been met in Level 3.5 setting. This criteria is met. For dimension 2, the patient is status post gastric bypass surgery and has hypertension. The patientas biomedical problems were stable and did not require medical or nurse monitoring. This criteria is met. For dimension 3, the patient was noted to complain of mild depression due to her weight gain after gastric bypass surgery. She had stopped drinking for approximately seven days prior to this admission and has a history of 90 days of sobriety. She was not suicidal or homicidal. She participated in groups. The patient meets sub-criteria of amental status is stable to permit participation,a but she does not meet any of the other qualifying criteria including aunable to control her use of alcohol and drugs with attendant probability of imminent danger,a or ademonstrates repeated inability to control her impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property,a or ademonstrates antisocial behavior patterns,a or ahas significant functional deficits, which are likely to respond to staff interventions...of pervasive nature requiring treatment that is primarily habilitative in focus; they do not require medical monitoring and management,a or aconcomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions.a This criteria is not met.
 For dimension 4, the patient admitted herself for treatment voluntarily as she was concerned about the effect alcohol was having on her marriage and health. She actively participated in treatment and was developing insight into her addiction. The patient does not meet the sub-criteria of alimited insight and little awareness of the need for continuing care...,a or ahas marked difficulty in understanding the relationship between her substance use, mental health, or life problems and her impaired coping skills and level of functioning, often blaming others for his addiction problems,a or ademonstrates passive or active opposition to addressing the severity of her addiction problem,a or arequires structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care,a or aperspective impairs her ability to make behavior changes without repeated, structured motivational interventions,a or aexpresses little to no interest in changing,a or aattributes her alcohol, drug or mental health problem to other persons or external events.a The patient does not meet this criteria. For dimension 5, the patient was drinking 8 mixed drinks daily. She had relapsed in January 2021. She has tried outpatient and IOP, but not in the past three years. She has previously been sober for 90 days. She recognized the need for treatment and continuing care. She had no suicidal ideation or homicidal ideation. She has never attempted suicide nor been aggressive. She was on medications for cravings. The patient does not meet criteria of alacks insight into benefits of continuing care and is therefore not committed to treatment,a or aunable to control use of alcohol or drugs with attendant probability of harm to self or others,a or aexperiencing craving...with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support,a or ain imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation,a or adespite recent active participation in treatment at a less intensive level of care, the patient continues to use alcohol or drugs,a or ademonstrates a lifetime history of repeated incarceration.a The patient does not meet this criteria. For dimension 6, the patient is married and lives with her husband and son. Her husband is requesting that she stop drinking and is supportive. The patient works as a social worker. The patient does not meet sub-criteria of aliving in an environment that is characterized by a moderately high risk of neglect, physical, sexual, or emotional abuse or...endemic substance abuse,a or apatientas social network includes regular users of alcohol and other drugs such that recovery goals are assessed as unachievable at a less intensive level of care,a or apatientas social network is characterized by significant social isolation or withdrawal such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care,a or apatientas social network involves living with an individual who is a regular user or dealer of other drugsa or apatient is unable to cope, for even limited periods of time, outside of a 24-hour care.a The patient does not meet this criteria. Thus, this patient does not meet Level 3.5 residential treatment criteria for dimensions 3, 4, 5 and 6. Therefore, residential treatment services (ASAM 3.5) provided from 4/13/21 through 5/05/21 were not medically necessary for the treatment of this patient.