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 provided.Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet 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 demonstrate any ongoing signs or symptoms of withdrawal. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient did not have documented medical issues. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had intermittent feelings of anxiety and symptoms of post-traumatic stress disorder (PTSD). She reported seeing two different therapists, including regular therapy sessions for five years. The patient did not present level of dysfunction so severe that she could not participate in a less structured or less intensive level of care, a repeated inability to control her impulses to use alcohol and other drugs, or to engage in antisocial behaviors, and was not at imminent danger of relapse with likelihood of harm to self, others, or property. She did not demonstrate antisocial behavior problems as evidenced by criminal activities or extreme lack of regard for authority, preventing movement towards positive change, and precluding participation in a less structured and intensive level of care, or significant functional deficits. She was not diagnosed with a comorbid personality disorder and did not demonstrate an inability to maintain stable behavior without the structure and support of a 24-hour setting. This criterion was not met.For dimension 4, the patient had a history of previous mental health treatment without prior substance use treatment. She was consistently described as motivated for recovery, learning coping skills, and demonstrating insight and awareness of her need for treatment. She was focused on setting boundaries with her parents. The patient did not demonstrate a perspective which impaired her ability to make behavior changes and did not require structured therapy in a 24-hour programmatic milieu to make progress in treatment. This criterion was not met.For dimension 5, the patient reported concerns about relapsing and anxiety about returning to her apartment. This was her first treatment for substance use. The patients treatment focused on her past trauma in both group and individual sessions. The patient recognized potential triggers for relapse and did not lack insight into the benefits of continuing care. There was no indication that the patient could not utilize resources to continue to work on sobriety in the absence of 24-hour monitoring and structured support, and she was not in imminent danger of relapse or continued use with dangerous emotional or behavioral consequences as a result of the crisis situation. This criterion was not met.For dimension 6, the patient had an apartment and was currently unemployed. The records did not support that the patients substance use was so endemic that she could not safely be treated at less intensive level of care or that she was unable to cope outside of a 24-hour care. 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 provided RTC services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment 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.