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

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with alcohol use disorder. The patient began intensive outpatient program (IOP) treatment.  He denied any history of violence while under the influence.  The patients urine drug screenings were negative. The patient endorsed low anxiety, rated as one to two. The patient reported attending 12-step meetings and having a sponsor. The patient endorsed developing relapse prevention tools. He reported that his anxiety continued to decrease. The patient indicated he had made an appointment with an outpatient therapist. The patient reported a decrease in cravings and triggers. The patient has requested reimbursement for IOP services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. At issue in this case is whether the IOP services that were provided were medically necessary for the treatment of the patients medical condition. The patient was noted to be collaborative and insightful into his need of treatment. He had no suicidal ideation, homicidal ideation, or signs of psychosis during treatment. The patient did not have serious medical issues that were affecting his treatment. There was no indication that the patient used substances during IOP treatment. He had a sober living environment and indicated support from his family and girlfriend. He was employed and did not endorse any legal issues. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, recovery environment, level of support, and treatment and recovery history. For risk of harm, the patients score is 1, due to a lack of current suicidal ideation or past suicide attempts. For functional status, the patients score is 1, due to transient impairment of functioning following the identified stressor of alcohol use. He is employed and his activities of daily living were intact. For comorbidity, the patients score is 2, due to the existence of medical problems that are not immediately threatening and have no impact on the course of his present illness. The patient endorsed episodes of mild anxiety. For recovery environment level of stress, the patients score is 1, due to no major losses of interpersonal relationships and his living environment posing no significant threats or risks. For recovery environment level of support, the patients score is 2, due to his girlfriend urging him to seek treatment and participating in his treatment. For treatment and recovery history, the patients score is 2, due to past sobriety for moderate periods of time with limited support. For engagement and recovery status, the patients score is 2, due to good cooperation in treatment, obtaining a sponsor, and attending 12-step meetings. The patients composite LOCUS score is 11, which correlates with clinic-based services without frequent contact.  Medical evidence does not support the services at issue in this clinical setting. Therefore, the requested IOP services that were provided were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry 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.