Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Intensive Outpatient Substance Use Treatment
The insurer denied: Intensive Outpatient Substance Use Treatment
The denial is overturned

The patient is an adult female. She was admitted/transferred to intensive outpatient program (IOP) level substance use disorder rehabilitation treatment in order to continue treatment following inpatient level rehabilitation treatment. The patient has a history of longstanding use of prescription opiates with escalating use over the five years prior to presentation for treatment. She was using 8-10 30 or 40 mg (milligrams) Percocet daily with significant impact on functioning and relationships with friends and family including job loss and social isolation and strained relationships with her immediate family. 

The patient lives with her spouse and mother-in-law. Stressors includes primary support, occupational, and social environment domains. There are no legal issues in this case, and the patient has trauma history.

The patient was developing a relapse prevention plan together with continued work on coping skills, and efforts continued to enhance her motivation to continue a recovery effort. The patient was deemed to be at high risk for relapse due to a lack of insight and no prior history of substance-related treatment or exposure to recovery groups. She was discharged from IOP (intensive outpatient program) level care against medical advice having completed most of her treatment goals and with consideration of clinically appropriate aftercare.

The health plan denied coverage on the basis of LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Guidelines indicating that the patient was improved with no general medical or psychiatric issues requiring IOP (intensive outpatient program) level care in the context of a supportive spouse. 

The Intensive Outpatient Substance Use Treatment was medically necessary.

The continued IOP (intensive outpatient program) substance use disorder rehabilitation treatment was medically necessary for this patient in order to effectively address the continuing clinical needs for rehabilitation treatment of severe opioid use disorders 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 and family environment including an appropriate disposition with sober supports, especially in working with the patient's community providers in developing a clinically appropriate disposition; 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 peer-supported groups in the community.

The continued IOP (intensive outpatient program) treatment through discharge was therefore medically necessary including continued monitoring for the duration of the proposed treatment in order to achieve a safe transition to lower-level treatment and transition to community level care. None of this therapeutic work could have been safely or effectively provided at a lower level of care.

This answer is consistent with prevailing standards of professional practice and ASAM (American Society of Addiction Medicine) criteria and scientific literature and published practice guidelines referenced below and is consistent with New York State OASAS (New York Office of Addiction Services and Supports) LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Guidelines and level of care assessment criteria.