Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
A patient is a 54-year-old male who was admitted to a residential treatment center (RTC) on 
9/19/22 and presented for a psychological evaluation. The patient has requested reimbursement 
for adult substance use disorder RTC from 9/26/22 through 10/17/22. 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 the American Society of Addiction Medicine (ASAM) criteria, 
this patient met Level 3.5 criteria for RTC services from 9/26/22 through 10/17/22. 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 had a history of delirium 
tremens, which has the potential to be fatal, and seizures when detoxifying from alcohol. The 
records noted up to seven detoxification attempts within the past four years, without significant 
sobriety. The patient was at high risk of death due to relapse and alcohol withdrawal. The patients 
withdrawal symptoms were safely managed in a level 3.5 setting. This criterion was met. For 
dimension 2, the patient reported medical symptoms including pain and swelling of his ankle and 
calf cramps. The records noted that the patient had an infected finger and cellulitis in the bilateral 
trunk. This criterion was met. For dimension 3, the records noted both psychiatric and cognitive 
difficulties  throughout  the  patients  stay, including  impaired  memory,  circumspect  answers, 
pressured speech, and hyper-attentiveness to details. He required redirection, appeared confused, 
and was described as anxious, with paranoia regarding hackers who were hijacking his life and 
causing difficulties in his finding employment. The patient was on antipsychotic medication along 
with gabapentin and hydroxyzine but remained anxious and exhibited classic symptoms for PTSD. 
He was prescribed Prazosin but reported insomnia and nightmares. The patient reported a history 
of anxiety and depression since age 12, when his brother committed suicide, citing this as a reason 
for starting opioid use. The patient appeared to be at high suicide risk due to being unmarried and 
unemployed, with alcohol and methamphetamine use disorders, a family history of suicide, and a 
lack of contact with his son. This criterion was met. For dimension 4, the patient was in the 
contemplative state of change. Although he had attended 12-step groups in the past, the patient 
reported wanting an alternative. The patient endorsed moderate cravings. The patient did not 
appear to be in the action stage of recovery/change. This criterion was met. For dimension 5, the 
patient was at a high risk for relapse due to a long history of drug and alcohol use, little sobriety 
time,  lack  of  supports,  and  endorsement  of  cravings.  The  patient  reported  use  of 
methamphetamine, which could be causing his paranoid delusions and/or making them worse. 
Continued use of methamphetamine would increase the patients paranoia and worsen his mental 
health issues. This criterion was met. For dimension 6, the patient was unemployed due to his 
mental health and substance abuse. He lived with his elderly father with whom he had a strained 
relationship. The patient reported support from a girlfriend but had been separated from her since 
2020. He lacked any support for his sobriety other than his current treatment team. This criterion 
was met. Given these findings, the patient met the six ASAM criteria for RTC services provided 
from 9/26/22 through 10/17/22. Accordingly, adult substance use disorder RTC from 9/26/22  through  10/17/22  was  medically  necessary  for  treatment  of  this  patient.