Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for inpatient rehabilitation center level of care at a facility that treats both borderline personality disorder and alcohol addiction. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 4 criteria for inpatient rehabilitation center level of care 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 records do not demonstrate that this patient requires Level 4 services, which are indicated for severe unstable withdrawal that needs 24-hour nursing care and the full resources of a licensed hospital. This criterion is not met. For dimension 2, the patient does not have significant biomedical complications of her alcohol use disorder requiring medical management and skilled nursing care, she does not have significant medical problems in which continued alcohol usage poses an imminent danger to life or severe danger to health, she is not having seizures or life-threatening symptoms related to her alcohol usage, and her alcohol usage is not exacerbating a previously diagnosed medical condition. This requirement is not satisfied based on the available records. For dimension 3, the patient has been diagnosed with borderline personality disorder, anxiety, and unspecified mood disorder. She has self-injurious behaviors but is not suicidal or homicidal. The records suggest that she has problematic family relationships and anger outbursts. The patient is in outpatient treatment and during her visit in August 2020, she reported that her mood was improved. On 10/2/20, the patient denied suicidal or homicidal ideation. She indicated that she is currently working full-time. There is no evidence of emotional, behavioral, or cognitive complications of the patients addictive disorder requiring psychiatric management and skilled nursing care or a concurrent emotional, behavioral, or cognitive illness requiring stabilization, daily psychiatric management and primary nursing interventions. There is a lack of evidence of mental confusion or fluctuating orientation that poses an imminent danger to self or others. There is not an emotional, behavioral, or cognitive disorder complicating the treatment of addiction that requires differential diagnosis and treatment, there is no impairment of patients thought processes or abstract thinking, and there is no evidence that continued alcohol use is causing grave complications of a previously diagnosed psychiatric condition. The patient is not experiencing altered mental status with or without delirium. There are no criteria on dimension 3 that are met.For dimension 4, the patient endorsed drinking 20 beers per day since May 2020 after a three-month period of sobriety. She also had an eight-month period of sobriety until November 2020, at which time she attended an addiction medicine program. The patients problems in dimension 4 alone are insufficient for placement at Level 4.For dimension 5, the patient has been able to maintain periods of sobriety with use of community services. The patients problems in dimension 5 alone are insufficient for placement at Level 4.For dimension 6, the patient lives alone and has one adult child. The patients problems in dimension 6 alone are insufficient for placement at Level 4.Per ASAM, a patient must meet at least one of the first three ASAM dimensions to meet the requirements for Level 4 inpatient level of care services. This patient does not meet any of the first three ASAM dimensions. Therefore, the patient does not meet the criteria for Level 4 inpatient level of care services. Accordingly, the requested inpatient rehabilitation center level of care at a facility that treats both borderline personality disorder and alcohol addiction is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are 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 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.