Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety, Depression
Treatment: Partial hospital program mental health treatment for 5 days a week, and 6 hours a day.
The insurer denied the partial hospital program mental health treatment for 5 days a week, and 6 hours a day.
The health plan's determination is overturned.

The patient is a male who presented as a step down from residential level care for partial hospital program (PHP) treatment in order to address unspecified anxiety and depressive disorders and co-occurring cannabis use disorder, as well as parent-child relational problems. The presentation included worsening symptoms of depression and anxiety with suicidal ideation, a decline in functioning and social isolation in the context of problematic behaviors including bouts of anger with verbal violence and irritability, sneaking out of his home, and substance use including daily use of cannabis together with intermittent use of hallucinogens (lysergic acid diethylamide (LSD) and Mushrooms) and alcohol with a binge pattern of use. 
He had an extensive history of outpatient treatment with medication management and psychotherapy, as well as the brief treatment episode with residential and intensive outpatient levels of care without sustained benefit.
At the time of admission for PHP level care, the mental status examination did reveal severe symptoms of depression with anxiety and anhedonia, hopelessness, and low self-worth. There was no evidence for psychosis, mood cycling, thought disorder, perceptual disturbance, severe cognitive impairment other than concentration and attention problems, or active suicidal ideation. His mood was dysphoric with low self-worth, and decreased energy, appetite, sleep disturbance and volition, as well as limited insight. He reported episodes of dissociation reflecting his psychedelic drug use with numbing and a sense of false reality.

The patient was provided treatment with intensive services, sober supports, safety monitoring, and structure provided within the PHP treatment program with five day per week services and sober living with structure and supervision and work on a recovery together with substance use counseling and 12-step recovery groups. He received group, family, individual and activity therapies including dialectical behavior therapy (DBT) and Motivational Enhancement Therapy (MET) and family focused sessions. He received ongoing psychiatric evaluations with medication management with use of Zoloft, Wellbutrin, Remeron, and melatonin with adjustments and titration as clinically appropriate last year with a regimen of Zoloft 75 milligrams (mg) twice daily, Wellbutrin extended release (XL) 150 mg, Remeron titrated to 15 mg and supplemental use of melatonin and vitamin D. 

The admission and continued PHP level intensity of services, structure, and monitoring were reasonable, in the best interest of the patient, and consistent with prevailing standards of medical practice. Specifically, the patient presented with worsening symptoms of the comorbid conditions with a decline in functioning, and related symptoms associated with substance use disorder with the cannabis class substance of abuse, as well as residual effects from the use of hallucinogens with dissociation. The patient was at high risk for relapse and had limited coping skills/insight-as noted in the clinical summary, and a treatment and recovery environment that was deficient in the context of parent-child relational problems, as well as treatment failure with lower-level services. These factors and treatment dimensions did warrant the admission and the continued PHP level services with sober supported housing, and intensive treatment with evidence-based therapy including DBT.  

The health plan's determination of medical necessity is overturned in whole.