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 (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 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 was treated for alcohol withdrawal with Librium earlier in his treatment stay. Based on clinical findings, the patients withdrawal needs can be met in Level 3.1 setting. For dimension 2, the patient does not have any reported medical problems. The patients biomedical problems, if any, are stable and do not require medical or nurse monitoring and the patient is capable of self-administering any prescribed medications. For dimension 3, the patient is described in the records as impulsive. The patient endorses drinking heavily to avoid thinking about his past trauma. He has diagnoses of major depression with psychotic features and severe post-traumatic stress disorder (PTSD). The patients home environment consists of being isolated in a trailer. He continues to lack coping skills to manage relapse triggers and is triggered by even seeing alcohol sold in stores. He has participated in individual and group therapies. 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. In addition, the patients symptoms and functional limitations, when considered in the context of his home environment, are sufficiently severe that he is assessed as not likely to maintain abstinence if treatment provided in a nonresidential setting. Functional limitations may include chronic addictive disorder and sequelae of emotional trauma. For dimension 4, the patient admitted himself for treatment voluntarily due to relapsing on alcohol three weeks after discharge from the same facility. The patient relapsed and was involved in a car accident while under the influence of alcohol. The patient was able to acknowledge negative consequences of his substance usage. The records support that the patient has acknowledged the existence of a substance use problem. He recognizes specific negative consequences and dysfunctional behaviors and their effect on his desire to change. He is sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1. For dimension 5, the patient endorsed drinking 30 beers or 1.5 liters of vodka daily. He relapsed on a camping trip with his family and had poor insight into relapse triggers or coping skills. He was involved in a car accident while intoxicated. The patient has demonstrated limited coping skills to address relapse triggers and urge. He thus is in imminent danger of relapse with dangerous behavioral consequences and needs 24-hour structure to help him apply recovery and coping skills. For dimension 6, the patient lives in a trailer on his parents property where he is physically and socially isolated. His parents reportedly enable his alcohol usage. He is reported as having little knowledge of coping skills or relapse triggers. The records document that the patient is able to cope, for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue clinical, vocational, educational, and community activities. In addition, the patients social network is characterized by significant social isolation and withdrawal. Given these findings, the patient meets the six dimensions to support ASAM Level 3.1 services. Moreover, the RTC services were and are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the RTC services (ASAM 3.1) 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.