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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  The progress notes indicate that this patient was and is motivated for treatment and has good insight into her need for treatment overall. Her health is stable and she has a supportive husband and a sober and supportive living environment. The progress notes do not indicate that the patient has any severe psychiatric symptoms. The progress notes indicate that the patient was to be started on Suboxone (buprenorphine) treatment for her opiate use disorder.  Suboxone treatment is an evidence based treatment of opiate use disorders and it shown to be effective for this condition. Buprenorphine treatment is regularly completed on an outpatient basis.  The American Society of Addiction Medicine (ASAM) has provided a set of guidelines regarding placement. Using the ASAM criteria, the services at issue were not and are not medically necessary. This patient demonstrates a rating score of zero with regards to acute intoxication and/or withdrawal potential, due to lack of withdrawal. With regards to her biomedical condition and complications, the patient has a risk rating score of one due to her stable medical problems. For emotional/behavioral or cognitive conditions and complications, the patient has a risk rating score of one indicating mild issues that are stable. For her readiness to change, the patient has a risk rating of zero due to her documentation of motivation to change and good insight and judgment. As to the dimension for relapse, continued use, or continued problem potential, the patient has a risk rating of one due to some periods of sobriety.  Lastly, with regards to recovery/living environment, the patient has a risk rating of zero due to a sober living environment with a supportive partner. Overall the patients presentation suggests risk rating scores within the range of zero to one.  This overall risk rating places the patient at a level one level of care according to the ASAM criteria. A level one is defined as outpatient services by ASAM guidelines/standards. Due to the patients overall low risk factors, medical health, and lack of severe psychiatric symptoms she did not meet criteria for IOP services. In summary, IOP services forward (18 sessions total) were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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.