Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Major Depressive Disorder and Polysubstance Abuse.
Treatment:  IOP treatment.   
The insurer denied IOP treatment.  The determination is overturned.

The patient is an adolescent female who presented for intensive outpatient program (IOP) level treatment for co-occurring disorders including major depressive disorder and social anxiety disorder in the context of polysubstance use disorder and severe psychosocial stressors.  The patient was abusing her Adderall (snorting) together with intermittent use of alcohol, hallucinogens, benzodiazepines, cocaine and cannabis, all of which were in the mild range except for the cannabis use disorder that was severe with persistent use.  She was having problems at school and at home with worsening symptoms of anxiety and depression and the co-occurring substance use that compounded her mental health conditions.

The patient's presentation for IOP treatment followed partial hospital program (PHP) level treatment with step down to IOP level care.  Again, she was receiving IOP level programming in the context of the severe psychosocial stressors and with encouragement from her parents, with whom she lived.  She had family stress related to her substance use and other stressors within the educational and social environment domains.

She presented with mood disturbance, social phobia and severe substance-related problems that had resulted in functional impairments and inability to maintain abstinence.  She had no prior substance use disorder treatment.  At the time of presentation, the patient was also reporting symptoms of depression and anxiety, for which she was prescribed medication-Prozac.  The patient provided no history of withdrawal seizures or delirium tremens.  She was medically screened and admitted for IOP level treatment with three days per week and three hours per day programming.  

There were no severe symptoms on mental status examination.  The patient was at high risk for suicidal behavior with few protective factors despite denial of suicidal ideation.  She had symptoms of depression including dysphoric mood and irritability with anxious affect and the social phobia.  The patient had limited knowledge of substance use disorder treatment and demonstrated impaired judgment, due to her underlying psychiatric disorders and poor decision-making skills, and directly due to the substance use including poor control of impulses, and cognitive impairment with memory and concentration difficulties, as well as underlying cognitive difficulties noted on previous neuropsychological testing.

The patient was admitted for IOP treatment. Her clinical course progressed slowly without incident.  However, she continued to display affective disturbance and reported intense craving during the initial weeks of treatment.  The patient was engaged in group and family focused sessions.  She received ongoing psychiatric management with titration of the Prozac as clinically appropriate to 40 mg, addressing symptoms of anxiety and depression.  She also was participating actively in group and educational sessions with the goal of developing improved coping skills and maintaining abstinence with periodic drug testing that was negative.

The case record indicates that the patient was working on issues within the family constellation and working to develop relapse prevention skills, as well as involvement in peer-supported recovery groups per her treatment plan.  The treatment plan also called for continued medication management.  Her mental status had improved with good sleep and appetite, improved mood and diminished anxiety with resolution of cravings and other persistent effects of the substance use.  She had gained insight with better judgment and control of impulses.  The treatment team was considering referrals and recommendations for clinically appropriate aftercare and consideration of a sober supports and participation in peer-supported recovery groups with continued support from her parents.

The case records, health plan documents, appeal documents, and correspondence from the health plan were reviewed, as well as records from prior evaluations and treatment.  This review is a New York State review with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.

Yes, the requested health service/treatment of intensive outpatient mental health treatment for 3 days a week, and 3 hours a day  is medically necessary for this patient.
The patient presented with a mood and anxiety disturbance and was using multiple substances of abuse on a daily continuous basis with severe psychosocial stressors and functional impairments that did warrant continued IOP level structure, monitoring and services.  The continued treatment for the co-occurring disorders diagnosed in this case could not have been effectively provided at a lower level of care for the time interval under review.  Moreover, the patient's social environment was not conducive to lower level treatment, and the patient had previously struggled with craving in the context of the mood disturbance and associated symptoms of anxiety with limited insight, impaired judgment and poor control of impulses.

Thus, despite the progress noted, the clinical features and treatment dimensions did necessitate the continued structure of an IOP level setting with intensive treatment, structure, supports, and monitoring for abstinence.  The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors and co-occurring psychiatric disorders do reflect a complicated clinical picture and do support the need for a safe and effective treatment setting, especially with regard to recent worsening of her co-occurring conditions.  The documentation clearly indicates that the patient was at high risk for treatment failure if the continued treatment were to be attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and consistent with the appropriate application of NY OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.