Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Continued Outpatient Substance Abuse Treatment

The insurer denied the Continued Outpatient Substance Abuse Treatment. The denial was reversed.  

This is a male patient who had a history of inpatient substance residential treatment but was unable to stop due to the short length of stay. He reported having two prior suicide attempts; he was hospitalized for one of them. He presented to a rehabilitation treatment facility for substance rehabilitation due to his continued use of cocaine, opiates and heroin, inhalants, hallucinogens, cannabis, and amphetamines. While in rehabilitation he attended individual and group therapy. His medication regimen included Wellbutrin and Lamictal. 

According to the American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders intensive outpatient programs are programs that provide an intensive, structured treatment experience for individuals with substance use disorders who require more services than those generally available in traditional outpatient settings. Alternatively, these programs are sometimes used as "step-down" programs for individuals leaving hospital or residential settings who are at a high risk of relapsing because of problems with motivation, the presence of frequent cravings or urges to use a substance, poor social supports, immediate environmental cues for relapse and/or availability of substances, and co-occurring medical and/or psychiatric disorders. The aim is to prepare the individual for transition to less intensive outpatient services and increased self-reliance through the practice and mastery of relapse prevention skills and the active use of self-help programs. 

The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that the best treatment outcomes occur with longer durations of treatment. Recovery from drug addiction is a long term process. It also states that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. His multiple serious substances of use significantly impaired his functioning so he did require at least substance intensive outpatient program treatment at least 3 hours per day 3 days per week so he met LOCADTR criteria for IOP treatment then. He did not have the reported coping skills to stop use without this intensive outpatient program treatment and needed this structure, supervision,  and support to monitor unsafe behaviors, improve coping skills and insight, identify relapse triggers, improve relapse prevention skills, make better choices, increased his support, and to try to maintain abstinence In this case this patient met criteria for at least intensive outpatient program treatment as he was a high risk patient who continued to use multiple serious substances of use despite past inpatient substance residential treatment, past negative consequences to use including 2 overdoses resulting in hospitalizations, past illegal activities including robbing and stealing, and he was homeless at one point. He continued to struggle with wanting to use substances during the denial period and also had reports of depression, suicidal ideation, self-harming behaviors, and even relapsed eventually while in residential treatment as he reportedly left the residential treatment to steal and drink alcohol. 

It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the patient.

Based on the above, the medical necessity for the continued intensive outpatient substance abuse treatment is substantiated.  The insurer's denial is reversed.