Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for all or any of the residential treatment center (RTC) services for a 90-day program. Per American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC. 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 with a valium taper. The patients withdrawal needs can safely be managed in level 3.5 setting. For dimension 2, the patient has chronic back pain. He reported drinking heavily for the past two and a half years. The patients biomedical problems were stable and did not require 24-hour medical or nurse monitoring. For dimension 3, the patient had diagnoses of major depressive disorder and post-traumatic stress disorder. The patient reported trauma from a history of abuse.  He had a prior hospitalization for expressing a plan to shoot himself with a gun. At admission, he endorsed periods of auditory hallucinations and suicidal ideation. The patients mental status was stable enough to permit participation, and he demonstrated functional deficits sufficiently severe that he was not likely to maintain abstinence in a non-residential setting.For dimension 4, this was the patients fifth admission to an RTC. While at the RTC, he reported significant psychiatric symptoms, including auditory hallucinations. He reported unresolved trauma and that his coping mechanism was alcohol. The patient's perspective impaired his ability to make behavior changes without repeated, structured, clinically directed motivational interventions and a 24-hour programmatic milieu. For dimension 5, the patient reported drinking heavily for the past two-and-a-half years despite multiple treatment attempts at different levels of care. He was arrested for driving under the influence. He had recently been hospitalized for suicidal ideation with a plan and continued to endorse suicidal ideation while at the RTC. Despite recent, active, participation in treatment the patient continued to use drugs with imminent serious consequences and was and is at high-risk of continued substance use in the absence of close 24-hour monitoring and structured treatment. For dimension 6, the patient is disabled and divorced. He reported being unable to see his three children and having unstable housing due to his alcohol usage. He does not have a social support system and is socially isolated. He is on probation for driving under the influence. The patient is unable to cope, for even limited periods of time, outside of 24-hour care and recovery goals were and are assessed as inconsistently unachievable at a less intensive level of care. 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, all the RTC services for a 90-day program were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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.