Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Partial Hospitalization Substance Use Disorder
The insurer denied the Partial Hospitalization Substance Use Disorder.
The denial is overturned.

The patient is an adult male re-admitted to partial hospital program (PHP) level substance use disorder rehabilitation treatment to address severe opioid and moderately severe cannabis use disorders. The patient has a history of substance use beginning in adolescence with cannabis and subsequent misuse of oxycodone escalating to use of heroin together with cannabis and tobacco. He denied use of other substances of abuse. The patient carried a diagnosis of obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder and a depressive disorder with associated treatments. His referral for substance-related treatment was prompted by the failure to remain sober despite access to treatment in the community and a relapse while in sober living with outpatient treatment.

The patient had a prior history of formal substance use disorder treatments and involvement in peer-supported recovery groups, and he had received mental health treatment including recent partial hospital program level services and involvement with self-help recovery groups. He had a history of several hospitalizations for heroin overdoses.

Evaluation on admission revealed a mental status examination without severe psychiatric symptoms including mania, psychosis, thought disorder and cognitive impairment (mental confusion). At the time of admission for partial hospital program level care, the patient was not clearly motivated for rehabilitation treatment due to minimization and lack of insight. The patient was described as having questionable judgment and limited insight with poor control of impulses. He denied active suicidal ideation or aggressive impulses, but did report energy and volition that were impaired. Also, he had experienced and reported symptoms of anxiety and insomnia, as well depression and anxiety identified upon entering treatment with residual anxiety and depressive turmoil together with post-acute withdrawal symptoms and intense craving. He was generally cooperative, but guarded in the pre-contemplative or contemplative stage of change. 

The patient had no significant general medical conditions. He had been medically cleared for partial hospital program level treatment. He was tobacco dependent. He was prescribed vitamin and nicotine replacement therapy, as well as a regimen of Paxil, gabapentin, and Vyvanse.

The patient is single with a General Education Development (GED); he lives with his parents who were supportive of his efforts to obtain treatment. Stressors included primary support, occupational, economic and social environment, as well as the severe and persistent mental disorders with the co-occurring disorders. There are no prominent legal issues or trauma history in this case though there is a remote history of 'driving under the influence' (DUI) arrest.

The patient underwent comprehensive psychiatric evaluation following admission to partial hospital program level care.  Substance use disorder rehabilitation treatment included focus on coping skills, relapse prevention with identification of triggers, education about the disease model of addiction, and, involvement with peer-support recovery groups, as well as plans for family-focused sessions when clinically appropriate. He received treatment with intensive services, sober housing/boarding, monitoring that included random drug screens, and structure provided within the rehabilitation treatment program and therapeutic milieu including five day per week programming and services, and the opportunity to attend daily 12-step recovery groups.

During the time interval in question, the patient was attending groups and participating in recovery groups and working on steps to facilitate his recovery. He continued to demonstrate cravings and was started on medication assisted treatment with buprenorphine (Sublocade). He continued to display anxious demeanor, and he was distractible with adjustments of his psychotropic regimen and a switch from buspirone and doxepin to gabapentin and zaleplon. He proved to be compliant with his treatment plan and had exposure to educational, group and peer supported recovery sessions in order to work on development of coping skills, a relapse prevention plan, and efforts to enhance his motivation to continue a recovery effort and the action stage of change. During partial hospital program level treatment, the patient was deemed to be at high risk for relapse with variable levels of motivation due to the craving and lack of insight, and co-occurring attentional and mood disorders and obsessive compulsive disorder (OCD) requiring active psychiatric management. 

The patient had reached 80 percent of his goals and the treatment team was recommending step down to less restrictive treatment setting and a sober living environment. He proceeded to intensive outpatient program (IOP) level care with continued plans for involvement with recovery groups and medication assisted treatment and treatment of the comorbid psychiatric disorders with monitoring for abstinence. Records show that he was discharged to the community.

The reason for denial by the health plan: the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines are not met including no comorbidity, no post-acute withdrawal syndrome (PAWS) or craving, no compliant issues, and no safety concerns/risk in a patient who was compliant with treatment and participating in treatment.

Appeal documents assert that patient has serious safety concerns with history of overdoses, significant comorbidity with obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD) and depression, requires medication assisted treatment for craving, and has a history of treatment failure and relapses despite in sober living and treatment in the community. Additionally, the appeal documents indicate that Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines are met.

Yes, the proposed treatment was medically necessary for this patient.
The patient's relapse and treatment failure in the community and safety concerns prompted the necessity for partial hospital program  level structure and monitoring and intensity of treatment through discharge/step down. The case is complicated by active substance use disorder with opioids/heroin and marijuana; and non-compliance with treatment in the community. The residual symptoms of mood and other psychiatric co-occurring disorders; co-occurring substance use disorders and treatment issues related to medication adjustments and starting medication assisted treatment and arranging a safe and appropriate discharge plan warranted the admission and the continued services at a partial hospital program (PHP) level of care in keeping with the American Society of Addiction Medicine (ASAM) Criteria and NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines as the appeal documents assert. 

Thus, contrary to the health plan's denial and inappropriate application of the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines, the substance use disorder partial hospital program (PHP) level treatment and services was therefore clinically appropriate and medically necessary, as the patient warranted the partial hospital program level structure and monitoring through the day of discharge when the patient was transferred to a lower level of care and less restrictive treatment setting with clinically appropriate follow-up and aftercare.

This answer is consistent with the scientific literature and published guidelines, and the American Society of Addiction Medicine (ASAM) Criteria referenced below, as well as New York State instruction for medical necessity reviews and the application of Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.