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

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with alcohol use disorder, major depressive disorder, and generalized anxiety disorder. On 6/21/18, the records noted that the patient appeared to be preoccupied and was less talkative. The patient has requested reimbursement for intensive outpatient program services received from 6/21/18 through 7/9/18. The Health Plan denied the services at issue and reported that the services were not medically necessary for the treatment of this patient. At issue is whether the requested intensive outpatient program services that the patient received from 6/21/18 through 7/9/18 were medically necessary for the treatment of this patient. On 6/21/18, the patient appeared to be preoccupied and was less talkative. She did not have any abnormal thoughts or psychosis. She did not have any medical issues. There was no report of this patient requiring assistance with activities of daily living. The patient was cooperative with care, actively involved in her treatment and participated in her treatment plan. The criteria for intensive outpatient treatment includes no risk of imminent or current risk of harm to self or others or property, and no risk of withdrawal or signs and symptoms of withdrawal that could be safely managed. Assessment, diagnosis, and treatment planning requires several days per week of structured observation and interaction in a program that maintains 9-19 hours per week for adults. The American Association of Community Psychiatrists Level of Care Utilization System is used in determining necessary level of care for adults. The patients scores are as follows:Risk of harm 1; due to a lack of current suicidal ideation and no self-harming behaviors. Functional status  2; due to some problems with comorbidity. Medical, addictive and psychiatric comorbidity  2 due to overall medical stability.Stress of the recovery environment  1; due to a stable living situation. Level of support for the recovery environment  1; due to family support and availability of treatment resources but also some difficulty in relationships with her family members. Treatment and recovery history  2 to 3; due to recent success at the intensive outpatient treatment program level of care. Engagement and recovery status 1; due to cooperation in treatment and insight into her need for treatment. Thus, the patient has a composite score of 10 to 11. This correlates with treatment in a community-based outpatient clinic setting. The patient was not actively attending the treatment and could be safely managed in a lower level of care as an outpatient. I have made this determination based on group therapy notes from 6/21/18 through 7/9/18. The medical evidence does not support the services at issue in this clinical setting. Therefore, the requested intensive outpatient program services received from 6/21/18 through 7/9/18 were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.