Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services.Per American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 has been sober from alcohol and other substances for the past three to four months. The patients withdrawal needs can be managed safely in a Level 3.1 setting.For dimension 2, the patient reports memory impairment and forgetfulness that affect her ability to function, and the records note a diagnosis of Wernicke-Korsakoff syndrome. The patients biomedical problems are stable and do not require 24-hour medical or nurse monitoring.For dimension 3, the patient has a diagnosis of depression and symptoms of cognitive impairment such as forgetfulness and feelings of disorientation. She lives with her mother and reports severe anxiety and decreased ability to maintain basic activities of daily living. The records note the patients participation in group therapy. The patients mental status is stable enough to permit participation, and her symptoms and functional limitations, when considered in the context of her home environment, are sufficiently severe that she is assessed as not likely to maintain mental stability and abstinence if treatment is provided in a nonresidential setting.  For dimension 4, the patient was admitted to the RTC with severe anxiety, confusion and symptoms of depression. She was socially isolated and unable to participate in outside activities. The records noted a lack of insight into triggers and coping skills to manage the urge to drink. The patient requires structured therapy and a 24-hour programmatic milieu to promote treatment progress and recovery because her perspective impairs her ability to make behavioral changes without the support of a structured environment. For dimension 5, the patient reported drinking heavily daily basis for the past year. Since her previous RTC stay, she had become socially isolated and withdrawn, and had not participated in community-based treatment. The records noted a diagnosis of Wernicke-Korsakoff syndrome. The patient demonstrates limited coping skills to address relapse triggers and urges and is at imminent danger of relapse with dangerous consequences in the absence of close 24-hour monitoring and structured treatment.For dimension 6, the patient lives with her mother. She was furloughed from her job, is socially isolated, and reports being by herself most of the time. She reports severe anxiety, disorientation, and memory loss. The patient demonstrates ability to cope for limited periods of time outside the 24-hour structure of a Level 3.1 program to pursue clinical activities. Continued exposure to the patient's work or living environment makes recovery unlikely, and the patient has insufficient resources and skills to maintain an adequate level of functioning outside of a 24-hour supportive environment.Given these findings, the patient meets the 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 were and are medically necessary for the 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 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.