Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and authorization and coverage for residential treatment center (RTC) services.Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient meets Level 3.5 criteria for residential treatment center services provided. ASAM criteria focus on six dimensions to determine the appropriate level of care. For dimension 1 - Acute Intoxication and/or Withdrawal Potential. Two weeks after admission, the patient still had mild to moderate withdrawal symptoms of anxiety, agitation, and tremors with Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores ranging from 4 to 12. Under these circumstances, the patients withdrawal needs could be met in a Level 3.5 setting.For dimension 2 - Biomedical Conditions and Complications. Records reflect that the patient had been recently hospitalized. His medical status was stable upon readmission to the residential treatment center. Therefore, the patients biomedical condition was not severe enough to warrant inpatient treatment.For dimension 3 - Emotional, Behavioral, or Cognitive Conditions and Complications. The patient has complaints of anxiety and depression. He reported chronic sadness, low motivation, and was noted to have an inability to cope with stressors. He was also noted to be very impulsive and prone to behavioral excess. For example, the patient reported that he spent all of his unemployment on drugs and alcohol. He also left this facility impulsively prior to the period under consideration in order to go use and then was hospitalized the following day. While the patients mental status permitted participation, he had a repeated inability to control his impulses to use alcohol and has been in imminent danger of relapse with the likelihood of harm to self.For dimension 4 - Readiness to Change. The patient was brought back to the residential treatment center by his mother to be readmitted after he left impulsively two weeks prior and then needed to be hospitalized. The patient has been drinking and using drugs since age 13 and heavily since age 16. He reported that he had only had one week of sobriety in the past. He has had serious consequences from his alcohol and drug usage including legal problems, unemployment, and homelessness. Because of the intensity and chronicity of the patients addictive disorder, he has limited insight and little awareness of his need for continuing care, and thus has limited readiness to change.For dimension 5 - Relapse, Continued use, Continued Use, or Continued Problem Potential. The period of residential treatment center services under consideration is the patient's second attempt at treatment, after leaving to use early in his first attempt at treatment. The staff noted that the patient had virtually no coping skills. The patient does not recognize his relapse triggers and lacks insight into the benefits of continuing care, and he is therefore not committed to treatment and poses an imminent risk of harm to self or others in the absence of close 24-hour monitoring and structured support.For dimension 6 - Recovery Environment. The patient is homeless. He has been unable to maintain employment and has been selling drugs. He does not have a sober support system. He has been unable to refrain from alcohol or drug usage in the absence of a structured setting. Accordingly, the patient is unable to cope, for even limited periods of time, outside of 24-hour care, and he needs staff monitoring to learn to cope with his recovery environment problems before being transferred safely to less intensive setting.Using the ASAM level 3.5 criteria worksheet, the patient meets all six criteria for medical necessity and therefore qualifies for ASAM Level 3.5 treatment. Accordingly, the requested residential treatment center (RTC) services were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services in issue and requested services were, and are, medically necessary to treat the patient's 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.