Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the partial hospitalization program (PHP) (ASAM Level 2.5) level of care services. Findings:  The physician reviewer found that Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 2.5 criteria for PHP services from 8/24/21 through 11/3/21. 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. Of note, the ASAM guidelines note that a patient may be transferred to Level 2.5 from a Level 1 or Level 2.1 program when the services provided at the less intensive level have proved insufficient to address the patient's needs.For dimension 1, the patient did not have withdrawal concerns. The patients withdrawal needs were met in Level 2.5 setting.For dimension 2, the patient had a history of sexually transmitted infections (STI), hypothyroidism, and dermatomyositis. The patient had biomedical conditions and problems that were not sufficient to interfere with treatment but are severe enough to distract from recovery efforts.For dimension 3, the patient had a diagnosis of depression. Problems in dimension 3 are not necessary for admission to a Level 2.5 program.For dimension 4, the patient continued to use substances despite intensive outpatient program (IOP) and residential treatment center (RTC) levels of care. He had quit his dental practice due to his substance use. He was being monitored by his professional society and was required to follow its treatment recommendations to not lose his dental license. Despite verbalizing readiness to change, the patient had not been able to maintain sobriety at a lower level of care due to an inability to sustain impulse control. The patient's perspective and lack of impulse control inhibited his ability to make behavioral changes without repeated, structured, clinically directed motivational interventions. Such interventions were not feasible or not likely to succeed in a Level 2.1 program. However, the patient's willingness to participate in treatment and to explore his level of awareness and readiness to change suggest that treatment at Level 2.5 could be effective. For dimension 5, the patient had attempted treatment at RTC and IOP levels of care and continued to use substances. He was noted as being at high risk of relapse and unable to maintain abstinence without a structured treatment setting. There was a high likelihood that the patient would continue to use or relapse to use substances without close outpatient monitoring and structured therapeutic services, as indicated by his lack of awareness of relapse triggers, difficulty in coping or postponing immediate gratification, or ambivalence toward treatment.For dimension 6, the patient was attending a program at a specialized treatment facility. He had stopped working at his dental practice and was mandated to this level of treatment by his professional society to prevent loss of his dental license.Given these findings, the patient met the ASAM dimensions for PHP services during the period under review. In this patients case, PHP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, PHP (ASAM Level 2.5) level of care services were medically necessary for the 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 psychiatry with sub-specialty 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.