Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder.
Treatment: Substance use disorder services.
The insurer denied coverage for substance use disorder services. 
The denial is overturned. 

This is a male patient who was admitted for substance intensive, outpatient program treatment after an inpatient substance rehabilitation treatment. He reportedly had severe opioid and severe alcohol use disorder. He attended 3 days per week of intensive outpatient program treatment and attended 32 sessions, after which he was referred to substance outpatient program treatment.

According to the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders , intensive outpatient programs provide an intensive, structured treatment experience for individuals with substance use disorders who require more services than those generally available in traditional outpatient settings. These programs are sometimes used as step-down programs for individuals leaving hospital or residential settings who are at a high risk of relapsing because of: problems with motivation, the presence of frequent cravings or urges to use a substance, poor social supports, immediate environmental cues for relapse and/or availability of substances, and co-occurring medical and/or psychiatric disorders. The goal of such a step-down approach is to stabilize patients by retaining them in treatment and providing more extended intensive outpatient monitoring of relapse potential and co-occurring disorders. The aim is to prepare the individual for transition to less intensive outpatient services and increased self-reliance through the practice and mastery of relapse prevention skills and the active use of self-help programs. The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide reports that the best treatment outcomes occur with longer durations of treatment. Recovery from drug addiction is a long term process. It also states that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. 

In this case, this patient's daily significant opiate and alcohol use impaired his functioning interpersonally and occupationally so this patient required substance intensive outpatient program treatment at least 3 hours per day 3 days per week. The patient met the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) criteria for intensive outpatient program (IOP) treatment. This patient met criteria for IOP treatment as he had been unable to maintain more than 3 weeks of abstinence and that was only after past inpatient detoxification treatment and inpatient rehabilitation treatment. He continued to report urges and cravings to use and was associating with his brother who was actively drinking alcohol. The patient was in an inpatient substance rehabilitation treatment and needed to transition from that setting to at least this intensive level of care. The patient reportedly had positive toxicology during the denial period and continued to struggle which indicated that he required at least this intensive outpatient program treatment then. 

The patient needed time in this structured and supervised IOP setting to further progress and improve further in coping skills, identifying triggers, interpersonal relations and communication, working on better identifying and accepting his addiction, building a sober support and not associating with active users, and better dealing with cravings. The patient was at high risk of relapse if he were stepped down too quickly to outpatient substance treatment as he could not maintain abstinence even after past inpatient substance treatments. 

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

The medical necessity for substance use disorder services is substantiated. The insurer's denial should be overturned.