Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for RTC services at the ASAM 3.1 level of care provided by The Lakes Treatment Center. Per American Society of Addiction Medicine (ASAM) criteria, this patient met 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 treated for alcohol withdrawal symptoms with benzodiazepines earlier in the stay. The patients withdrawal needs were safely managed in a Level 3.1 setting. For dimension 2, the patient has arthritis and transaminitis. The patients biomedical problems are stable and do not require medical or nurse monitoring. For dimension 3, the patient was noted as being anxious. She reported drinking heavily on a daily basis and had a history of blackouts. She reported having fallen and hitting her head multiple times,  and of becoming angry and acting impulsively when in a blackout. The patients mental status is stable enough to permit participation, her psychiatric condition is stable, and she is assessed as having minimal problems in this area, as evidenced by both of the following: (1) the patient's anxiety and depression may be related to substance use problems or to a stable co-occurring emotional, behavioral, or cognitive condition, with imminent likelihood of relapse with dangerous consequences outside of a structured environment, and (2) the patient is assessed as not posing a risk to self or others.For dimension 4, the patient admitted herself for treatment voluntarily due to an incident of drinking excessively with her boyfriend, resulting in a confrontation and her boyfriend being jailed. She was able to acknowledge negative consequences of her alcohol use including falling, aggression, legal charges, and relationship problems. The patient acknowledged the existence of a substance use problem, recognized specific negative consequences and dysfunctional behaviors and their effect on her desire to change, and is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient reported drinking up to a fifth of whiskey daily. She had a prior RTC stay, along with detoxification, but relapsed directly out of the facility. The records noted poor insight into an abusive relationship with her boyfriend of several years as the couple drank together and had episodes of violence. The records noted a history of relationships involving domestic violence. The patient reported wanting to continue the relationship, and that this would not jeopardize her recovery. The patient understands her addiction and/or mental disorder but is at risk of relapse in a less structured level of care because she is unable to consistently address either or both.For dimension 6, the patient lives with her boyfriend who also has an alcohol use disorder. They are in an abusive relationship, and she has poor insight into the risks of continuing to live with him. The patient reports having a sober social support network. The patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities, and has been living in an environment that is characterized by moderately increased risk of repetition of physical, or emotional abuse that the patient is assessed as being unable to achieve or maintain recovery at a less intensive level of care.Given these findings, the patient met six ASAM criteria for RTC services. In this patients case, RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not 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, RTC services at the ASAM 3.1 level of care provided by The Lakes Treatment Center 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 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.