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 the American Society of Addiction Medicine (ASAM) criteria, this patient meets 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 still has mild to moderate post-acute withdrawal symptoms of agitation, anxiety, and headache after completing a Librium taper earlier in his admission. The patients withdrawal needs can be met in Level 3.5 setting. For dimension 2, the patient had a recent hospital admission for peptic ulcer disease which was likely secondary to his alcoholism. He also has a history of hypertension. Ongoing alcohol usage would put him at risk for gastrointestinal bleeding. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, which can be provided by the program. For dimension 3, the patient has diagnoses of PTSD and depression. Of note, he has attempted suicide at least three times and two of these attempts took place within the past year. He continues to have significant PTSD and depressive symptoms and he is having difficulty coping with PTSD symptoms and drinking as a means of coping. He had documentation of an outburst in group. There are multiple incidents in which the patient had severe insomnia. The patients mental status is assessed as sufficiently stable to permit the patient to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patient has significant functional deficits which are likely to respond to staff interventions. These symptoms and deficits, when considered in the context of his home environment, are sufficiently severe that the patient is not likely to maintain abstinence if treatment is provided in a non-residential setting. The functional deficits are of a pervasive nature and include residual psychiatric symptoms and inadequate anger management skills. For dimension 4, the patient was admitted to RTC after he attempted suicide while intoxicated. He has been drinking a pint and a half of vodka daily for 20 years. He reports that he drinks to manage nightmares, insomnia, and other PTSD symptoms. He has limited coping skills to manage these symptoms and was recently started on a selective serotonin reuptake inhibitor and prazosin. The patients perspective impairs his ability to make behavior changes without repeated, structured, clinically directed motivational interventions, which will enable him to develop insight into the role he plays in his substance use disorder and mental condition, and empower him to make behavioral changes which can only be achieved in a 24-hour milieu. For dimension 5, the patient has been drinking heavily on a daily basis for the past 20 years. Prior treatment has included RTC level of care, most recently in 2019 for three weeks. He also has significant depression and PTSD symptoms that have affected his ability to remain sober. He has attempted suicide two times while intoxicated in the past nine months. The patient is in imminent danger of relapse or continued use, with dangerous emotional, behavioral, or cognitive consequences, as a result of a crisis situation. For dimension 6, the patient lives with his wife who has a substance use disorder. His social network is composed of other drinkers. The patients social network involves living with an individual who is a regular user such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. Given these findings, the patient meets the six ASAM dimensions for RTC level of care services. Therefore, RTC services were and are medically necessary for 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 with subspecialty certification in addiction medicine 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.