Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any residential treatment center (RTC) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient met 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 was treated with a diazepam taper. The patients withdrawal needs were safely managed in a level 3.5 setting. For dimension 2, the patient had peripheral neuropathy due to her drinking. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient reported being overwhelmed with grief from the death of her father and two brothers and coping with the losses by drinking and sleeping for over 15 hours per day. Following the loss of her cat, the patient reported drinking and driving aimlessly, blacking out, and being found sitting in the middle of the road, intoxicated. She continued to have strong urges to drink while at the RTC. She participated in groups. The patients mental status was stable enough to permit participation. Despite her best efforts, the patient demonstrated an inability to control her drinking, and was in imminent danger of relapse with attendant likelihood of harm to self. For dimension 4, the patient admitted herself for treatment following a six to eight-hour blackout when she was found sitting in the middle of the road miles away from her home. She reported drinking since age 23 and was drinking one and a half bottles of wine and 375 mL of vodka daily. Her longest period of sobriety was ten days ten years ago, and she was last sober for five days approximately one year ago. This was her first attempt at residential or formal treatment. The patient attributed her drinking to her grief and loss. She reported that her daughters were not speaking to her. She reported that her husband was a sommelier and that there were large quantities of wine at home. The patient required structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery, because her perspective impaired her ability to make behavior changes. For dimension 5, the patient reported drinking one and a half bottles of wine plus 375 mL of vodka daily. She had a five-day period of sobriety approximately one year ago. She had tried to stop drinking on her own with the help of virtual Alcoholics Anonymous meetings. She subsequently relapsed, with an episode of driving drunk for several hours and sitting in the middle of the road until help arrived. This was her first attempt at treatment. The patient was assessed as having minimal to no coping skills and lacking awareness of a need to change. She was started on Campral to manage her urges to drink and continued to experience strong cravings for alcohol. The patient had persistent addiction cravings with imminent serious consequences and was at high-risk of continued alcohol use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient was unemployed. She was married and lived with her husband and two teenage daughters. She was living in the basement of the house due to her drinking. Her husband was a sommelier and there were large quantities of alcohol in the house. The patient had tense relationships with her family members. The patients living environment was highly invested in alcohol such that recovery goals were assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient met the six ASAM criteria for RTC services. In this patients case, RTC level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were 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, the RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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.