Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Intensive outpatient substance use treatment, revenue code 0906.
The insurer is denied coverage for intensive outpatient substance use treatment, revenue code 0906.
The denial is overturned. 
This is a male patient who was admitted to the substance intensive outpatient program treatment due to the need for substance and alcohol rehabilitation. The patient reportedly had increased cocaine use to snorting 2 lines daily, 2 hits of cannabis daily, and he reportedly relapsed on alcohol after a 20-year history of abstinence. With this relapse, the patient reported comorbid depressive and anxiety symptoms including sad and anxious mood, feelings of worthlessness, low self-esteem, weight loss and decreased appetite, poor sleep, attention problems, and impulsivity. The patient was using these substances alone at nighttime. The patient's psychiatric history was also significant for diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, and Attention Deficit Hyperactivity Disorder (ADHD) and was also taking Adderall in addition to substance use disorders. The patient's medical history was significant for diabetes, prostate cancer, and Lyme's disease. The hospital course of treatment and management included medication management, 12-steps program, and individual and group therapy. After treatment, the patient was cleared for discharge with follow-up to outpatient program.

According to the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders intensive outpatient programs are programs that provide an intensive, structured treatment experience for individuals with substance use disorders who require more services than those generally available in traditional outpatient settings. Alternatively, these programs are used for patients who are at a high risk for relapsing because of problems with motivation and presence of frequent cravings or urge to use a substance, poor social supports, immediate environmental cues for relapse and/or availability of substances, and co-occurring medical and/or psychiatric disorders. The goal is to stabilize patients by retaining them in treatment and providing more extended intensive outpatient monitoring of relapse potential and co-occurring disorders. Intensive outpatient programs use individual therapy, group therapy, family therapy, and urine toxicology but vary in the amount of
other therapeutic components used. The aim is to prepare the individual for transition to less intensive outpatient services and increase self-reliance through the practice and mastery of relapse prevention skills and the active use of self-help programs. As per the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide, the best treatment outcomes occur with longer durations of treatment.

In this case, this patient required this intensive outpatient treatment as he was using dangerous substances such as cocaine daily while taking prescribed medication such as Adderall which put this patient at high medical risk for cardiac issues. The patient's comorbid psychiatric issues including depression and anxiety, and past history of suicide attempt, are all risk factors for this patient who reporting active symptoms, such as sad and anxious mood, feelings of worthlessness, low self-esteem, weight loss and decreased appetite, poor sleep, attention problems, and impulsivity. It was reported that this patient's parents died from a home invasion when he was a child. The patient lacked sober supports and was living alone.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for intensive outpatient substance use treatment, revenue code 0906 should be overturned. The medical necessity is substantiated.