Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for all or any of the intensive outpatient program (IOP) (ASAM 2.1) level of care. Findings:  The physician reviewer found that (ASAM) criteria this patient met Level 2.1 criteria for IOP services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued. Of note, problems in dimensions 1, 2 and 3 are not necessary for admission to a Level 2.1 program, so these criteria will not be reviewed. According to the ASAM criteria, IOP placement is indicated for patients meeting criteria in at least one of dimensions 4, 5, or 6.For dimension 4, the patient was noted to be in the preparation and action stage of change. She was motivated for treatment and actively participated. The patient was sufficiently ready to change and cooperative enough to respond to treatment at Level 2.1.  For dimension 5, this was the patient's first attempt at treatment. The records noted that the patient was beginning to identify triggers, such anger, for drinking. The records noted that the patient continued to present as anxious and angry. The patient had a high likelihood of relapse without close outpatient monitoring and structured therapeutic services, as indicated by her lack of awareness of relapse triggers or ambivalence toward treatment.For dimension 6, the patient had a high stress environment due to occupational, financial, and relationship pressures. She reported tension in her marriage due to her history with alcohol. She was trying to manage a situation with her parents residing in her rental home without paying rent. The patient reported feeling anxious and angry. She continued to work on developing a sober social network. Continued exposure to the patients current living environment rendered recovery unlikely, and the patient lacked the skills necessary to maintain an adequate level of functioning without the services of a Level 2.1 program. While her recovery environment was not supportive, the patient was able to cope with structure and support and relief from the home environment.Given these findings, the patient met dimensions 5 and 6 of the ASAM criteria for IOP services provided. In this patients case, IOP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not a primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Accordingly, IOP (ASAM 2.1) level of care was medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.