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 underwent withdrawal management for alcohol withdrawal. He has demonstrated withdrawal symptoms including tremors, anxiety, and insomnia. The patients withdrawal needs can be safely managed in Level 3.5 setting. For dimension 2, the patient was reportedly recently diagnosed with Parkinsons disease. The patients biomedical problems, if any, are stable and do not require 24-hour medical or nurse monitoring, and the patient is capable of self-administering any prescribed medications.For dimension 3, the patient was diagnosed with depressive disorder and anxiety in the aftermath of his recent diagnosis of Parkinsons disease two months prior to admission. He has demonstrated difficulty managing anxiety since he has used alcohol to cope his entire adult life. The patient exhibited anger outbursts when feeling anxious or distressed and he tried to manipulate his family to let him return home. The provider indicated that the patient has participated in groups. The patients mental status has been assessed as sufficiently stable to allow 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 not provided in a non-residential setting. The functional deficits are of a pervasive nature. They may include residual psychiatric symptoms and chronic addictive disorder. For dimension 4, the patient admitted himself voluntarily at his familys insistence due to an increase in his drinking after his diagnosis of Parkinsons disease. The patient endorses drinking nearly a fifth of liquor daily for 25 years and drinking alcohol daily for 40 years. His drinking has increased to being throughout the day over the past several months. He has demonstrated poor insight into his alcohol use. The patient has repeatedly denied that he is an alcoholic or that he has a severe alcohol use disorder. The patient indicated that he would be able to return to drinking socially. Because of the intensity and chronicity of the addictive disorder or the patients mental health problems, he has limited insight and little awareness of the need for continuing care or the existence of his substance use problem and need for treatment, and thus has limited readiness to change. For dimension 5, the patient has been drinking alcohol daily for the past 40 years and drinking nearly a fifth of liquor daily for 25 years. The patient has been using alcohol to manage his anxiety and mood for his entire adult life. The provider noted that the patient has poor insight into triggers for his drinking and he minimizes his usage and problems. The patient has expressed that he can return to drinking socially after treatment. The patient does not recognize relapse triggers and lacks insight into the benefits of continuing care and is therefore not committed to treatment. His continued substance use poses an imminent danger of harm to self or others in the absence of 24-hour monitoring and structured support. For dimension 6, the patient lives with his wife and adult daughter. His family is supportive of his sobriety. He does not have an outside sober support system. He associates alcohol usage with social gatherings and parties. He has been recently diagnosed with Parkinsons disease and he has been managing his significant depression and anxiety with alcohol. The patients drinking has escalated to throughout the day since his diagnosis. The patient is unable to cope, for even limited periods of time, outside of 24-hour care. He needs staff monitoring to learn to cope with Dimension 6 problems before he can be safely transferred to a less intensive setting. Given these findings, the patient meets the six ASAM dimensions for RTC services. Therefore, the RTC level of care 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.