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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement, and authorization and coverage, for intensive outpatient program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes during the disputed period indicate that the patient was cooperative in treatment and that much of her anxiety was based around her potential for relapse. Although she had anxiety about relapse it was not clear that she relapsed during the disputed timeframe. The progress notes did not reflect any symptoms of substance withdrawal or intoxication during her therapy. She was noted to use coping skills and therapeutic techniques in order to decrease her anxiety and increase her ability to relax.  She appeared to suffer from some anxiety and depression during her treatment. Per the literature, various psychotherapy treatment options are effective for control of major depressive disorder such as trying to behavioral therapy and interpersonal therapy.The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services allows providers to determine the necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1. There was a lack of current suicidal ideation. With regards to functional status, the records support a score of 2 due to overall good functional level. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with some substance abuse issues that appear under good control. In terms of level of stress of the recovery environment, the records support a score of 2. She had a stable living environment. With regards to level of support of the recovery environment, the records support a score of 2 due to mention in the records that her boyfriend was supportive of her. In terms of treatment and recovery history, the records support a score of 3 due to good recent treatment response in the IOP in the recent past. With regards to engagement and recovery status, the records support a score of 2 due to good cooperation in treatment. Thus, the patient has a composite score of 13. This score correlates with a treatment intensity level of one, which is recovery maintenance health management. Thus, the patient could have safely been treated in a less restrictive setting. Therefore, intensive outpatient program services provided from 7/14/18 through the present and ongoing, were not and are not medically necessary for the treatment of this patient. 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.