Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder. 
Treatment: Partial hospitalization treatment. 

The insurer denied coverage for partial hospitalization treatment. 

The denial is overturned. 

This adult male was admitted to substance rehabilitation treatment for substance rehabilitation treatment and work on his unresolved trauma issues, depression, and anxiety. He reportedly was drinking 6-8 vodka drinks, using up to 1 12 grams of cocaine daily, and also using MDMA (3,4-methylenedioxymethamphetamine), mushrooms, LSD (lysergic acid diethylamide), molly, and ketamine. He reportedly had multiple blackouts and a past DUI (driving under the influence) charge. His longest reported abstinence was 4 weeks after his DUI. The recommendation was for inpatient substance rehabilitation treatment. He reportedly had trauma issues as he was the victim of sexual and physical abuse, was self-medicating his trauma and depressive symptoms, had anxiety, hopelessness, decreased self-worth, PTSD (post-traumatic stress disorder), obsessive compulsive, and dissociative symptoms. He attended group, individual, and family therapy, EMDR (Eye Movement Desensitization and Reprocessing), and took Wellbutrin, Prozac, and Naltrexone. His Prozac was increased to 80 milligrams (mg) per day. He reportedly was living with his wife and children. He was discharged after completing treatment. 
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that partial hospitalization programs can provide an intensive, structured treatment experience for individuals with substance use disorders who require more services than those generally available in traditional outpatient settings. It also is used in patients who are at a high-risk period for relapse because of life circumstances or recurrence of a co-occurring medical or psychiatric symptom. 

This patient had multiple substance use and a past DUI and was unable to maintain abstinence. He also had serious comorbid multiple psychiatric issues and had unresolved severe trauma issues contributing to his use. He lacked insight into how his psychiatric issues contributed to his self-medication with alcohol and multiple serious substances used. He could not maintain abstinence in a less restrictive level of care, so he required at least daily supervised and structured multimodal treatment in this PHP (partial hospitalization program) setting. 

According to the American Society of Addiction Medicine (ASAM) he met criteria for at least level 2.5 PHP. On dimension 3 (Emotional/Behavioral Conditions) he reportedly had major depression, PTSD, obsessive compulsive symptoms, anxiety, sexual acting out, dissociative symptoms, gambling, hopelessness, suicidal ideation at times, and decreased self-worth. On dimension 4 (Treatment Acceptance/Resistance) he reportedly had minimal awareness of continued danger to use, did not have intrinsic motivation, had significant shielding defenses, lacked insight, and lacked awareness of the powerlessness of his addiction. On dimension 5 (Relapse/Continued Use Potential) he was considered a risk for relapse as he had limited coping skills and limited ability to identify triggers for relapse. On dimension 6 (Recovery/Environment) it was reported that he was unable to stop use without being in a 24-hour therapeutic setting. He required at least the 5 days per week treatment in this multimodal supervised and structured partial hospital program treatment. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for partial hospitalization treatment is overturned. Medical Necessity is substantiated.