Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Substance Abuse Outpatient

The patient is a female with a history of opioid use disorder, cocaine use disorder, depression, and anxiety. The patient reportedly had a relapse on fentanyl. She was emotional and crying as she talked about spirits. She described feeling very overwhelmed. The patient was stepped up to the partial hospitalization program level of care at the time of her relapse. On this date, she had no suicidal or homicidal ideation and was stated to have a euthymic mood. There was a plan to place her on a naltrexone long-acting injection. Psychiatric evaluation listed diagnoses of opioid use disorder, cocaine use disorder, major depressive disorder, recurrent, moderate. She was dysphoric and irritable in her psychiatric interview and remorseful about her relapse. Clinical history was significant for diagnoses of depression and anxiety. She was prescribed Wellbutrin to stabilize her mood. She reported being compliant with medications. The patient had multiple episodes of substance use disorder treatment including detoxification admissions, residential treatment admission, partial hospitalization program episodes of care, and intensive outpatient program episodes of care. Clinical documentation describes her as having cooperative behavior, anxious mood, and disheveled appearance. She denied suicidal or homicidal ideation. She described having anxiety at a level of 9 and depression at a level of 7. She reported cravings at 9. She reported post acute withdrawal symptoms of vomiting, lack of appetite, severe tiredness, bodyaches, and mood instability. She was prescribed Zanaflex, gabapentin, Wellbutrin, Subutex, and ferrous sulfate. The health plan's determination is upheld. The requested health service/treatment of Partial Hospitalization Substance Use Treatment is not medically necessary for this patient. American Society of Addiction Medicine (ASAM) Levels of Care Criteria. Assessment of the six Dimensions of these criteria for this patient are as follows:
Dimension 1: Acute Intoxication and/or Withdrawal Potential -The patient had post-acute withdrawal symptoms after her relapse. It seems that she had become sick due to also being on buprenorphine. Post acute withdrawal symptoms were described as nausea, tiredness, pain. There was no evidence of acute withdrawal symptoms.
Dimension 2: Biomedical Conditions/Complications -There is no evidence in the clinical documentation that the patient had unstable biomedical conditions during the dates of service in question or that biomedical conditions were a significant barrier to treatment at a lower level of care.
Dimension 3: Emotional/Behavioral/ Cognitive Conditions and Complications -The patient reported depression and anxiety and rated her symptoms at a high level. The patient had no suicidal or homicidal ideation, intent, or plan, but her mental health symptoms were significant and increased her risk of relapse.
Dimension 4: Readiness to Change -The patient has been documented to be motivated for treatment and change. The patient was actively participating in groups and other treatment offerings.
Dimension 5: Relapse/Continued Use/ Continued Problem Potential -While the patient did have a significant risk of relapse based on a history of past relapses, the patient had been sober for a period of time until her recent relapse. She had worked on developing coping skills and supports to maintain sobriety.
Dimension 6: Recovery Environment -The patient had access to stable housing and good sober supports.
The clinical profile above is not consistent with the need for partial hospitalization program level of care. The results of this review are also supported by Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) criteria. Though the patient had a relapse, she was well engaged with treatment. She had some post acute withdrawal symptoms but no acute withdrawal symptoms or potential for acute withdrawal symptoms. Medical issues were minimal. She did have mental health concerns that complicated her treatment course, but she was not unstable psychiatrically. She was participating in groups and in treatment offerings actively and had medication assisted treatment. She could have been safely and effectively treated at a lower level of care.