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. Findings:  The physician reviewer found that 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 admitted to RTC. He completed withdrawal management with Librium taper. The patients withdrawal needs can be met in Level 3.1 setting.For dimension 2, the patient has hypertension, GERD, anemia, and chronic back pain. He was noted to be frail and a fall risk. The patients biomedical problems, if any, are stable and do not require medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient has diagnosis of PTSD with nightmares, insomnia, anger dyscontrol, and hypervigilance. He has been using alcohol to cope with his PTSD symptoms. He has been participating in groups. 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 he is assessed as having minimal problems in this area as evidenced by anxiety may be related to substance abuse problems with imminent likelihood of relapse outside of structured environment and the patient is assessed as not posing a risk of harm to self or others. For dimension 4, the patient voluntarily admitted himself to RTC as he recognized the effect his drinking was having on his health and ability to function. He was assessed as being in the preparation stage of change. The patient acknowledges the existence of substance use problem. He recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He is sufficiently ready to change and cooperative enough to respond to treatment at level 3.1. For dimension 5, the patient has been drinking a pint of vodka daily for the past three years. He has attempted to quit on his own, but he experienced withdrawal symptoms. He has been unaware of relapse triggers. He has been frequently irritable and reports ongoing insomnia. He was assessed as drinking in response to symptoms of PTSD. The patient has sustained falls and blackouts due to his alcohol use disorder. The patient demonstrates limited coping skills to address relapse triggers and urges. He is in imminent danger of relapse with dangerous consequences and needs 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient will be living alone and is retired without any structure to his life. He is socially isolated. 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. The patient lacks social contacts and his social network is characterized by significant social isolation and withdrawal leading recovery goals to be assessed as unachievable outside of a 24-hour supportive setting. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC level of care 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 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.