Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse/Mental health. 
Treatment: Partial hospital program (PHP) level substance use disorder treatment and mental health treatment. 

The insurer denied the partial hospital program (PHP) level substance use disorder treatment and mental health treatment. The denial is overturned. 

This case involves an adult female admitted to partial hospital program (PHP) level substance use disorder treatment of severe alcohol use disorder and a co-occurring mood disorder. The admission for partial hospital program (PHP) level substance use disorder rehabilitation services occurred in the context of a history of failed treatment episodes in the past with residential treatment, and the admission represented her fifth attempt at substance use disorder treatment. Her presentation for substance use disorder treatment was prompted by deterioration in family and social functioning. She was using alcohol on a daily continuous use in large quantity including box wine and vodka. She had a history of frequent blackouts and drinking to the point of passing out with a binge pattern of use and had experienced delirium tremens (DTs) in the past. The patient denied use of other substances of abuse. 

The patient had been treated in the past for co-occurring major depressive disorder and unspecified anxiety disorder with panic attacks and social and generalized symptoms of anxiety, attention deficit hyperactivity disorder (ADHD), and she had a past diagnosis of borderline personality with trauma history (post-traumatic stress disorder). Her psychotropic medication regimen included Prozac, Buspar, and trazodone with as needed (PRN) use of hydroxyzine and past treatments with Concerta and Adderall. 

During her brief stay, the patient began working to develop a plan for step down to intensive outpatient program (IOP) level treatment including work with her family to assure better sober supports. There was consideration of restarting a stimulant to address her problems with attention and concentration. She was discharged from PHP level services with step down to intensive outpatient program (IOP) level care for continued rehabilitation services and the development of a safe and clinically appropriate discharge plan. The discharge plan called for continued intensive treatment of the co-occurring disorders to include involvement in peer-supported recovery groups with the obtainment of a sponsor. 

Yes, the requested health service of Partial Hospital Program Treatment was medically necessary for this patient. 

The Partial Hospital Program Treatment was medically necessary for this patient in order to effectively address the continuing clinical needs for rehabilitation treatment of severe alcohol use disorder with evidence-based psychosocial treatments, and to work toward relapse prevention; in order to address the patient's lack of awareness of the seriousness of her illnesses with psycho-education and recovery groups; and in order to address issues within the social environment including development of an appropriate disposition with sober supports; and, in order to work on coping skills that will be necessary in building a sober support system and continued recovery efforts with community providers and engagement with 12-step recovery groups and a sponsor. 

The patient was noted to have ongoing cravings and persistent post-acute withdrawal symptoms that rendered her at high risk for relapse. A psychotropic medication regimen was used for treatment of the co-occurring psychiatric disorders combined with cognitive behavioral therapy and trauma-related interventions. The patient's continued struggle with mood disturbance and severe psychosocial stressors warranted the admission and continued PHP level structure and monitoring to assure abstinence while working on the development of relapse prevention plan and coping skills that were critical in this case together with necessary gains with insight that facilitated acquisition of better coping skills. 

Thus, the admission and continued PHP level treatment provided the clinically appropriate components of the treatment that were provided with necessary and appropriate structure, intensity of services, and monitoring. The continued PHP treatment through discharge was therefore medically necessary including continued monitoring for abstinence for the duration of the proposed treatment in order to achieve stability and make a safe transition to lower level treatment and transition to IOP level care. None of this therapeutic work could have been safely or effectively provided at a lower level of care in view of the multiple, complicating factors in this case for the time interval under review.