Appeal type: Medical Necessity
Decision: Upheld

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) (ASAM Level 3.5) services. Per American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for RTC services. For dimension 1, the patient was managed for alcohol withdrawal earlier in their treatment course. The patients withdrawal needs were safely managed in a Level 3.5 setting. For dimension 2, the patient had injuries from a motor vehicle accident. 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 PTSD. They did not have a recent history of overdose or aggressive behaviors. The records noted that the patient was able to focus on their recovery and relapse prevention. The patients mental status was stable enough to permit participation, but the records did not indicate that they were unable to control their use of alcohol or was in imminent danger of relapse, with attendant likelihood of harm to self, others, or property, demonstrated antisocial behavior patterns, had significant functional deficits of a pervasive nature requiring treatment that is primarily habilitative in focus that were likely to respond to staff interventions, or concomitant personality disorders of such severity that the accompanying dysfunctional behaviors provided opportunities to promote continuous boundary setting interventions. This criterion was not met.For dimension 4, the records did not indicate that the patient had limited insight and little awareness of the need for continuing care, marked difficulty in understanding the relationship between substance use, mental health, or life problems and their impaired coping skills and level of functioning, demonstrated passive or active opposition to addressing the severity of their addiction problem, or required structured therapy and a 24 hour programmatic milieu because motivational interventions had not succeeded at less intensive levels of care. The patient did not have a perspective that impaired their ability to make behavior changes without repeated, structured motivational interventions, express little to no interest in changing, or attribute their alcohol, drug or mental health problem to other persons or external events. This criterion was not met. For dimension 5, the patient reported drinking one handle of hard alcohol daily. The patient recognized the need for treatment and continuing care, and had worked on uncovering reasons for the recent relapse. The records did not indicate that the patient lacked insight into benefits of continuing care and was therefore not committed to treatment, was unable to control use of alcohol or experiencing cravings with the situation posing an imminent danger of harm to self or others in the absence of close 24-hour monitoring and structured support, was in imminent danger of relapse with dangerous emotional, behavioral, or cognitive consequences as a result of a crisis situation, continued to use alcohol despite recent active participation in treatment at a less intensive level of care, or demonstrated a lifetime history of repeated incarceration. This criterion was not met.  For dimension 6, They were planning on returning to their previous living situation upon discharge, had signed up for an IOP, and planned on attending AA groups. The records did not indicate that the patient was living in an environment characterized by a moderately high risk of neglect or of endemic substance abuse, or that the patient was unable to cope for even limited periods of time, outside of 24-hour care. The patient did not have a social network including regular users or dealer of substances, or have a social network characterized by significant social isolation and withdrawal, such that recovery goals are assessed as inconsistently unachievable at a less intensive level of care. This criterion was not met.Given these findings, the patient did not meet the six ASAM criteria for RTC services. In this patients case, RTC level of care was not and is not in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were not and are not clinically appropriate in terms of type, frequency, extent, site, and duration. Accordingly, RTC (ASAM Level 3.5) services 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 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.