Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Partial Hospitalization Substance Use Treatment
The insurer denied the Partial Hospitalization Substance Use Treatment
The denial is overturned.

The patient is an adult male. He was admitted to partial hospital program (PHP) level substance use disorder rehabilitation treatment to address severe opioid (Percocet) and cannabis use disorders. The patient has a history of substance use beginning in adolescence with cannabis, and subsequent misuse of Percocet following exposure after a medical procedure. He denied use of other substances of abuse. He reported progression to daily continuous use of marijuana and regular use of up to 15 mg (milligrams) of Percocet. The patient carried a diagnosis of schizophrenia with history of affective instability and psychosis that included paranoid-driven behavior and hyper-religiosity for which he was prescribed lithium and quetiapine. His referral for substance-related treatment was prompted by the failure to remain sober despite access to treatment in the community together with family encouragement.

The patient had no prior history of formal substance use disorder treatments or involvement in peer-supported recovery groups, but he had received mental health treatment, including three prior inpatient psychiatric admissions for mood disturbance and psychosis.

The patient's evaluation on admission revealed a mental status examination with severe psychiatric symptoms, including mania, psychosis, thought disorder and cognitive impairment (mental confusion). At the time of admission for PHP (partial hospitalization program) level care, the patient was not clearly motivated for rehabilitation treatment due to minimization and lack of insight. The patient was described as having questionable judgment and limited insight with poor control of impulses. He denied active suicidal ideation or aggressive impulses, but did report paranoid thought and was preoccupied with religious themes, talking directly with God. His energy and volition were impaired. Also, he had experienced and reported symptoms of anxiety and insomnia, as well as the grandiose and paranoid-driven behaviors that were identified upon entering treatment with residual anxiety and psychotic turmoil together with post-acute withdrawal symptoms and intense craving. He was generally cooperative, but guarded in the pre-contemplative stage of change.

The patient had no significant general medical conditions. He had been medically cleared for PHP (partial hospitalization program) level treatment. He was tobacco-dependent at one pack per day use. He was prescribed vitamin and nicotine replacement therapy.

The patient is single, high school-educated, and employed with family. He lives with his parents, who were supportive of his efforts to obtain treatment. Stressors included primary support, occupational, economic and social environment, as well as the severe and persistent mental illness. There are no prominent legal issues or trauma history in this case.

The patient underwent comprehensive psychiatric evaluation following admission to PHP (partial hospitalization program) level care.  Substance Use Disorder Rehabilitation Treatment included focus on coping skills, relapse prevention with identification of triggers, education about the disease model of addiction, and involvement with peer-support recovery groups, as well as plans for family-focused sessions when clinically appropriate. He received treatment with intensive services, sober housing, monitoring and structure provided within the rehabilitation treatment program and therapeutic milieu including five day per week programming and services, and the opportunity to attend daily 12-step recovery groups.

During the time interval, the patient was attending groups and participating in recovery groups and working on steps to facilitate his recovery. He continued to demonstrate cravings and continued PAWS (post-acute-withdrawal syndrome). He continued to display erratic behavior that was disruptive, and he was distractable with strange mannerisms. He proved to be non-compliant with his treatment plan despite exposure to educational, group and peer supported recovery sessions in order to work on development of coping skills, a relapse prevention plan, and efforts to enhance his motivation to continue a recovery effort. During treatment, the patient was deemed to be at high risk for relapse with variable levels of motivation due to the craving and lack of insight and co-occurring psychotic and mood disorder.

The treatment team was recommending a higher level of care in a more restrictive treatment setting that could address the schizoaffective disorder. His family arranged for a transfer to inpatient residential treatment with discharge.

Yes, the Substance Use Disorder Partial Hospital Program (PHP) level treatment and services were medically necessary for this patient.
The patient's persistent symptoms of psychosis and mood disturbance together with continued risk of erratic behavior, and risk for non-adherence to medication prompted the necessity for PHP (partial hospitalization program) level structure and monitoring through discharge. The case is complicated by active substance use disorder with prescription opioids and marijuana; and non-compliance with treatment and medication non-adherence. The residual symptoms of mood and psychotic disorder (schizoaffective disorder); co-occurring substance use disorder and treatment issues related to medication adjustments and arranging a safe and appropriate discharge plan warranted the continued services at a PHP (partial hospitalization program) level of care in keeping with ASAM (American Society of Addiction Medicine) Criteria and NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR  (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines.

The Substance Use Disorder Partial Hospital Program (PHP) level treatment and services were therefore clinically appropriate and medical necessary, as the patient warranted the PHP (partial hospitalization program) level structure and monitoring through the day of discharge when the patient was transferred to a higher level of care and more restrictive treatment setting with clinically appropriate follow-up and aftercare.

This answer is consistent with the scientific literature and published guidelines, and the ASAM (American Society of Addiction Medicine) Criteria referenced below, as well as New York State instruction for medical necessity reviews and the application of NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR  (level of care for alcohol and drug treatment referral) 3.0 Criteria.

The Substance Use Disorder Partial Hospital Program (PHP) level treatment and services could not have been safely or effectively provided at a lower level of care. Thus, the requested benefit of Substance Use Disorder Partial Hospital Program (PHP) level treatment and services is reasonable and in the patient's best interest, and is consistent with prevailing standards of medical practice for the treatment of the conditions diagnosed in this case.