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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient program services. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The progress notes indicate that the patient transitioned from a partial hospital program to an intensive outpatient program with success. The progress notes do not indicate that the patient had suicidal or homicidal ideation, and she was not experiencing any psychosis. She had some anxiety symptoms in regards to her eating disorder. It appears that the patient was open in treatment and receptive to feedback from her providers. The records indicate that she was able to follow her meal plan for a majority of the time.  She was not displaying any aggressive behaviors and was not exhibiting self-harm behaviors. Per the literature, therapy on a consistent basis along with medication treatment is the most successful for eating disorder treatment overall. In this patients case, regular outpatient therapy would have been effective, safe, and medically appropriate. The literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for the treatment of eating disorders.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. There was a lack of current suicidal ideation. With regards to functional status, the records support a score of due to overall fair functional level. In terms of medical, addictive and psychiatric comorbidity, the records support a score of due to overall medical stability and no severe substance issues. In terms of level of stress of the recovery environment, the records support a score of. She had a stable living environment. With regards to level of support of the recovery environment, the records support a score of due to an overall supportive recovery environment. In terms of treatment and recovery history, the records support a score of due to minimal treatment response in the past, but also minimal past history of treatment. With regards to engagement and recovery status, the records support a score of due to good cooperation in treatment. Thus, the patient has a composite score of.  This score correlates with low intensity community based services. Thus, the patient could have safely been treated in a less restrictive setting. Therefore, intensive outpatient program services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.