Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cannabis use disorder
Treatment: Partial Hospital Substance Use Disorder Treatment
The insurer denied the Partial Hospital Substance Use Disorder Treatment
The denial is upheld.

The patient is a male who was reported to have been admitted to a substance abuse partial hospitalization level of care. He was noted to have been diagnosed with cannabis use disorder (F12.20). He was also reported to have been diagnosed with generalized anxiety disorder (F41.9), major depressive disorder, recurrent, moderate (F33.1) and chronic pain (G89.29). The patient was reported to have been admitted to the substance abuse partial hospitalization level of care for treatment of persistent symptoms of cannabis use disorder. The patient was reported to have been initially admitted to a residential treatment level of care. He was noted to have been subsequently stepped-down to partial hospitalization level of care.

The patient was reported to have a significant history of cannabis abuse. He was reported to have started using cannabis with gradual increase over time. The patient was reported to have been using cannabis to cope with symptoms of depression and anxiety as well as pain related to a soccer injury. The patient was reported to have been abusing cannabis daily. He was also reported to have been abusing stimulants (Ritalin and Adderall) and alcohol. The patient was reported to have a history of hallucinations following significant cannabis abuse. The patient was reported to have a history of withdrawal symptoms including hot and cold flashes, decreased appetite, and nausea. He was reported to have a history of social, interpersonal, educational, legal and physical health consequences related to cannabis abuse. He was noted to have been arrested after police found two ounces of marijuana in his dorm room and charged him with possession and intent to distribute. There was no indication that the patient had any significant history of severe withdrawal in the past, including withdrawal seizures, or delirium tremens.

No, the proposed treatment (substance abuse partial hospitalization level of care from was not found to be medically necessary.
Based on current peer-reviewed, evidence-based medical literature, the requested substance abuse partial hospitalization level of care was not found to be medically necessary. The clinical information provided does not indicate that the requested service was the least restrictive setting that was medically necessary or would be successful in treating the patient's ongoing symptoms (1-6). The patient is a male who was reported to have been admitted to a substance abuse partial hospitalization level of care. He was noted to have been diagnosed with cannabis use disorder (F12.20). He was also reported to have been diagnosed with generalized anxiety disorder (F41.9), major depressive disorder, recurrent, moderate (F33.1) and chronic pain (G89.29). The patient was reported to have been admitted to the substance abuse partial hospitalization level of care for treatment of persistent symptoms of cannabis use disorder.

The clinical information provided does not indicate that the patient had any significant ongoing symptoms of substance use disorder at the time of his admission to the partial hospitalization program. There was no indication of the patient had any ongoing unstable vital signs, or abnormal biochemical parameters. The patient was not reported to have any significant post-acute withdrawal symptoms or cravings. Clinical information provided does not indicate that the patient had any significant physiological withdrawal symptoms. There was no indication of the patient was at immediate risk of relapse outside of a structured setting.

The patient was not reported to have any significant ongoing behavioral health symptoms including depression or anxiety that required the continuing structure of a partial hospitalization program at the time of his admission. The patient was not reported to have any suicidal or homicidal ideations with plans or intent. He was not reported to have any symptoms suggestive of psychosis including command hallucinations, persecutory delusions or extreme paranoia. He was not reported to have exhibited any significant agitation or aggression. He was not reported to have any symptoms of mania or hypomania. The patient had no significant ongoing medical problems that required interventions or monitoring. He was not reported to have any significant functional impairments including activities of daily living and self-care that represented a change from his baseline. He was not reported to have had any significant adverse effects from medications. There was no indication of the patient had any significant barriers to continuing treatment at a lower level of care including severe psychosocial stressors, lack of social support or unsafe living environment. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care.

The proposed treatment is not required to diagnose or treat an illness, injury, disease or its symptoms; is not in accordance with generally accepted standards of medical practice; is not clinically appropriate in terms of type, frequency, extent, site and duration; and is not rendered in the least intensive setting that is appropriate for the delivery of the services and supplies.

Yes, the health plan was noted to have acted reasonably, with sound judgment and in the best interest of the patient.
The clinical information reviewed does not indicate that the patient had any significant ongoing symptoms of substance use disorder that required the continuing structure of a partial hospitalization program. There was no indication that the patient had any significant withdrawal, post-acute withdrawal symptoms or cravings that required continuing programming in a partial hospitalization level of care. There was no indication of the patient had any significant comorbid medical or behavioral health condition that required the intensive interventions of a partial hospitalization program. The patient was not reported to have any significant functional impairments including age-appropriate activities of daily living and self-care that represented a change from his baseline. The patient may have been treated safely and effectively in a less restrictive setting and lower level of care. Therefore, the health plan was noted to have acted reasonably, with sound judgment and in the best interest of the patient for the denial of coverage for partial hospitalization program.