Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mental Health
Treatment: Mental Health Outpatient
The insurer denied: intensive outpatient mental health treatment
The denial is: Overturned in whole


The patient is a female who was admitted to partial hospital program (PHP) level services and stepped down for intensive outpatient program (IOP) level treatment for co-occurring disorders including major depressive disorder and social anxiety disorder in the context of polysubstance use disorder and severe psychosocial stressors. The patient was abusing her Adderall (snorting) together with intermittent use of alcohol, hallucinogens, benzodiazepines, cocaine, and cannabis all of which were in the mild range except for the cannabis use disorder that was severe with persistent use. She was having problems at school including school refusal and had problems at home with a tendency to isolate and with worsening symptoms of anxiety and depression and the co-occurring substance use that compounded her mental health conditions.

She was receiving IOP level programming in the context of the severe psychosocial stressors and with encouragement from her parents with whom she lived. 

The patient initially presented with mood disturbance, social phobia and severe substance-related problems that had resulted in functional impairments and inability to maintain abstinence. She had no prior substance use disorder treatment. At the time of presentation, the patient was also reporting symptoms of depression and anxiety for which she was prescribed medication-Prozac at 20 milligrams (mg) daily. The patient provided no history of withdrawal seizures or delirium tremens. She was medically screened and admitted for IOP level treatment with three day per week and three hours per day programming.

The patient was admitted for IOP treatment. Her clinical course progressed slowly without incident. However, she continued to display affective disturbance and reported intense craving during the initial weeks of treatment.  The patient was engaged in group and family focused sessions, as well as other activities designed to enhance social skills and functioning. She received ongoing psychiatric management with titration of the Prozac as clinically appropriate to 40 mg and then to 60 mg, addressing symptoms of anxiety and depression. Low dose bupropion was added to offset sexual side effects.  The subject under review is the IOP treatment which was denied by the plan.

The health plan's determination is overturned, in whole. The requested treatment could not have been and cannot be effectively provided at a lower level of care in this case scenario. The patient in this case presented with a mood and anxiety disturbance and was using multiple substances of abuse on a daily continuous basis with severe psychosocial stressors and functional impairments that did warrant continued IOP level structure, monitoring and services. Moreover, the patient's social environment is not conducive to lower level treatment in view of persistent symptoms and the Covid-19 Pandemic, and the patient had previously struggled with craving in the context of the mood disturbance and associated symptoms of anxiety with limited insight, impaired judgment and poor control of impulses that continues to put her at high risk for relapse.

The clinical features and treatment dimensions did/do necessitate the continued structure of an IOP level setting. The documentation clearly indicates that the patient was at high risk for treatment failure if the continued treatment were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, and this determination is in keeping with  prevailing standards of care and the guidelines and scientific literature, referenced below, American Society of Addiction Medicine (ASAM) Criteria and the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.
Therefore, the intensive outpatient mental health treatment is medically necessary.