Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM Level 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for RTC services. The 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 managed for alcohol withdrawal earlier in his treatment stay. The patients withdrawal needs can be safely managed in a Level 3.5 setting. For dimension 2, the patient does not have significant medical problems. The records document a history of cyclic vomiting, but this has been well managed for a few years. The patients biomedical problems have been stable and do not require medical or nurse monitoring. For dimension 3, the patient is noted as being diagnosed with major depressive disorder and generalized anxiety disorder. The patient has not been suicidal or homicidal. He does not have history of overdose, suicide attempts, or aggressive behaviors toward others. The provider reports that the patient has participated in groups. The patients mental status has been assessed as sufficiently stable to permit participation in the therapeutic interventions provided at this level of care and to benefit from treatment. However, the patient does not meet any of the other qualifying criteria such as inability to control his use of alcohol and drugs with attendant probability of imminent danger, demonstrating repeated inability to control his impulses to use alcohol and other drugs and is in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, or demonstrating antisocial behavior patterns. The records do not indicate that the patient has significant functional deficits, which are likely to respond to staff interventionsof pervasive nature requiring treatment that is primarily habilitative in focus, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provide opportunities to promote continuous boundary setting interventions. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 4, the patient admitted himself for treatment voluntarily. The patient has been able to admit that his substance use is a problem. The patient has participated in his treatment milieu, and he has expressed interest in changing. However, there is a lack of evidence that the patient requires 24-hour programmatic milieu to sustain motivation. Thus, the patient does not meet the remaining criteria such as having limited insight and little awareness of the need for continuing care, having marked difficulty in understanding the relationship between his substance use, mental health, or life problems and his impaired coping skills and level of functioning, demonstrating passive or active opposition to addressing the severity of his addiction problem, or requiring structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care. There is a lack of documentation that the patients perspective impairs his ability to make behavior changes without repeated, structured motivational interventions, that the patient expresses little to no interest in changing, or that he attributes his alcohol, drug or mental health problem to other persons or external events. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 5, the patient endorsing use of 3.5 grams of cocaine daily. The provider charted that the patient recognizes his need for treatment and continuing care. The patient denies suicidal and homicidal ideation. The patients records do not document that he lacks insight into benefits of continuing care and is therefore not committed to treatment, or unable to control use of alcohol or drugs with attendant probability of harm to self or others, experiencing craving...with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support. There is a lack of documentation that the patient is in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, that despite recent active participation in treatment at a less intensive level of care the patient continues to use alcohol or drugs, or that he demonstrates a lifetime history of repeated incarceration. Based on these findings, the patient does not meet the requirements for this dimension. For dimension 6, the patient lives alone. The patient reports that his friend group consists entirely of people use substances. The patients social network includes regular users of alcohol and other drugs such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care.The ASAM criteria requires adult patients to meet all six dimensions to support Level 3.5 RTC services. This patient does not meet Level 3.5 RTC criteria for dimension 3, 4, or 5. Moreover, the RTC services were not in accordance with the generally accepted standards of mental health and substance use disorder care, and not clinically appropriate in terms of type, frequency, extent, site, and duration. For these reasons, the RTC services (ASAM Level 3.5) were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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  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.