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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 10 additional sessions of continued Intensive Outpatient Program (IOP) services.The submitted documentation supports that 10 additional sessions of continued Intensive Outpatient Program (IOP) services are medically necessary. In cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System is indispensable in determining the necessary level of care for adults. Taking the above into account, the patient may be assigned a risk of harm rating of 2, which corresponds with a low risk of harm. The patient may be assigned a functional status rating of 3, which corresponds with moderate impairment. This scoring reflects that the patient continues to be troubled in most significant relationships involving family, and he lacks other interpersonal relationships. In assessing the patients coexisting disorders, the patient may be assigned a comorbidity rating of 3, as the patient has significant co-morbidity. This is because the patient had episodic substance use (most recently involving cannabis) that occurred despite negative consequences and had significant impact on his mood, anxiety, and eating disorder. The patients most recent use was arrested through the use of a highly structured setting, and he continues to have significant depressive and anxiety symptoms that have an adverse effect on his urges to use alcohol or substances and engage in eating disorder behaviors. The patients recovery environment may be assigned a level of stress rating of 3, to correspond with a moderately stressful environment, and a level of support rating of 3, to correspond with limited support in his environment. The patients environment included significant discord in his family relationships, alienation from social interactions, loss of employment, deterioration of material circumstances, and a current residence in a sober living facility. Records reflect that the patient has not achieved optimal control of his symptoms, and his partial recovery has only been maintained in the past by being in structured settings. When added together, these ratings produce a composite score of 19, which indicates that the patient qualifies for a Level 3: High Intensity Community Based Services level of care. High Intensity Community Based Services are characterized by treatment programming (including group, individual, and family) three days per week and psychiatric staffing for review and/or contact as needed, according to initial and ongoing assessment. This level of care is consistent with the requested Intensive Outpatient Program (IOP) services. Therefore, 10 additional sessions of continued Intensive Outpatient Program (IOP) services are medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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.