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 and intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient does not meet Level 3.5 criteria for RTC services, but the patient does meet the criteria for Level 2.1 IOP 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 did not show evidence of significant alcohol withdrawal. Based on clinical findings, the patients withdrawal needs could have been safely managed in a Level 3.5 setting.For dimension 2, the patient does not have significant medical problems. The patients biomedical problems, if any, were stable and did not require 24-hour medical or nurse monitoring, and the patient was capable of self-administering any prescribed medications. For dimension 4, the patient admitted herself for treatment voluntarily. The patient was able to admit that she has alcohol use disorder and she participated in her treatment. She expressed interest in changing. There is a lack of documentation to support that she required 24-hour programmatic milieu to sustain motivation. Overall, the patient did not exhibit limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between her substance use, mental health, or life problems and her impaired coping skills and level of functioning, often blaming others for her addiction problems, or passive or active opposition to addressing the severity of her addiction problem. The records do not support that the patient required structured therapy and a 24-hour programmatic milieu because motivational interventions have not succeeded at less intensive levels of care, or perspective impaired her ability to make behavior changes without repeated, structured motivational interventions, that the patient expressed little to no interest in changing, or that she attributed her alcohol, drug or mental health problem to other persons or external events. Given these findings, the patient did not meet the requirements for this dimension.For dimension 5, the patient endorsed drinking five vodka drinks five times weekly and smoking cannabis daily. She recognized the need for treatment and continuing care. The patient did not have any suicidal or homicidal ideation, or history of suicide attempt. The records do not establish that the patient lacked insight into benefits of continuing care and was therefore not committed to treatment, 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, or in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation. The records do not indicate that despite recent active participation in treatment at a less intensive level of care, the patient continued to use alcohol or drugs, or that the patient demonstrated a lifetime history of repeated incarceration. Given these findings, the patient did not meet the requirements for this dimension.For dimension 6, the patient was in college and living with friends who drink alcohol. She has family support and was contemplating other living arrangements. The patients social network involved living with an individual who is a regular user, addicted user or dealer of alcohol or other drugs. Based on these findings, the patient did not meet ASAM Level 3.5 RTC requirements for dimensions 3, 4, or 5. The ASAM guidelines require adult patients to meet all six dimensions to support Level 3.5 RTC services. Moreover, the RTC services were not in accordance with the generally accepted standards of mental health and substance use disorder care, or clinically appropriate in terms of type, frequency, extent, site, and duration for treatment of this patient. Therefore, the RTC services (ASAM 3.5) were not medically necessary for treatment of this patient. With regard to the IOP services, per the ASAM criteria, this patient meets Level 2.1 criteria for IOP services. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. Of note, problems in dimensions 1, 2, and 3 are not necessary for admission to a level 2.1 program. According to the ASAM criteria, IOP placement is indicated for patients meeting the requirements in at least one of Dimensions 4, 5, or 6. For dimension 4, the patient has been motivated for treatment and has actively participated in her treatment milieu. Thus, the patient does not meet the requirements for this dimension. For dimension 5, this is the patients first attempt at treatment. She has not been regularly attending 12-step meetings. She has been struggling with feeling left out since her friends post pictures of drinking and using substances on social media. She has been thinking about testing her sobriety. She is still struggling with figuring out how to socialize with peers that are sober. Based on these reports, there is a high likelihood that the patient will relapse without close outpatient monitoring and structured therapeutic services, as indicated by her lack of awareness of relapse triggers, difficulty in coping, or ambivalence toward treatment. For dimension 6, the patient is living in an apartment after leaving a sober living environment. She continues to work on developing a sober social network and learning how to socialize with sober peers. She reports that all of her former friends were drinkers or used substances. The records document that the patient lacks social contacts, has unsupportive social contacts that jeopardize recovery, or has few friends or peers who do not use alcohol or other drugs. She also lacks the resources or skills necessary to maintain adequate level of functioning without the services of a Level 2.1 program. Final Result: The reviewer determined that a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.