Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for subacute residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for the 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 patients withdrawal needs were safely managed in the Level 3.5 setting. Her protracted withdrawal symptoms were consistent with a hyper-glutamatergic state seen with chronic alcohol use, and likely contributed to her significant cravings. The provider noted that the patient experienced withdrawal symptoms including agitation, visible tremor, headache, struggles with focus and concentration. For dimension 2, the patients current biomedical condition is not severe enough to require an inpatient treatment, however, is sufficient to distract from her treatment and recovery efforts. The patients tendency to seek out high-risk situations when using includes high-risk sexual behaviors, consuming alcohol with her medication, and her documented contraction of gonorrhea further highlight this risk. For dimension 3, the patients mental status is sufficiently stable such that she did not require inpatient admission, and she was able to participate in groups and treatment in this RTC level of care. However, she continued to demonstrate significant psychiatric distress that warranted this level of care. Specifically, the patient experienced a significant panic attack that was so severe that staff intervention was required and the providers made changes to her medications to target her distressing symptoms. Although there was no evidence of a delirium, the provider noted that the patient demonstrated an elevated hyperadrenergic state that could have triggered a relapse on alcohol. The treatment regimen at this RTC level of care provided the requisite action needed to treat her emergent anxiety needs. For dimension 4, the patient required structured therapy and a 24-hour programmatic milieu to promote her treatment progress and recovery as she has not succeeded at lower level of care with outpatient and Alcoholics Anonymous (AA) based interventions. The patients longest period of sobriety has been only two weeks while in a lower level of care. Due to the chronicity and intensity of her alcohol and amphetamine use disorders, she was at imminent danger should she continue her substance use disorder. For dimension 5, the patients psychiatric symptoms posed a moderate to high risk of relapse on substances and this situation posed an imminent danger of harm to self in the absence of close 24-hour monitoring and structured support. The patient exhibited a limited ability to apply her relapse prevention skills. She has shown a consistent inability to cope with her anxiety symptoms, which were of sufficient severity to place her at a grave risk of relapse and harm. For dimension 6, the patients social network includes users of substances and alcohol such that recovery goals were assessed as inconsistently achievable in a less intensive level of care. The patient reported that her boyfriend also drinks alcohol and she is currently homeless. Her social and community environment is not supportive of good mental health functioning. She could easily devolve into previous patterns of antisocial and high-risk behaviors. Given these findings, the patient meets the six required ASAM dimensions to support treatment at the RTC level of care. For these reasons, the subacute RTC services were medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 * 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