Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.
Treatment: Continued substance IOP (intensive outpatient program) treatment.
The insurer denied coverage for continued substance IOP treatment.
The denial is overturned.

This adult male was approved for substance intensive outpatient program (IOP) treatment due to alcohol, benzodiazepine, and cannabis use. He also had depressive symptoms, anxiety, fatigue, and had cravings for use. He reportedly lacked coping skills for sustained abstinence and was considered at risk for relapse. He took psychotropic medications including Viibryd, Buspirone, Atenolol, Hydroxyzine but stopped Viibryd eventually and had Bupropion added and transcranial magnetic stimulation (TMS) therapy started and also took L-Methyl folate.
  
The insurer denied coverage for continued substance IOP treatment. They stated that he did not require 3 or more days per week of substance treatment and that he had identified multiple coping skills. They recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for continued substance IOP treatment through the last medical record date as the chart notes provided enough specific evidence to support that patient required this level of care then.

The Milliman Care Guideline (MCG) Outpatient Program Behavioral health level of care IOP guidelines state that criteria is met if one is a low risk of danger to self or others, has mild to moderately severe psychiatric or behavioral conditions, has mild to moderate dysfunction in living, and that this level of care is likely to improve or likely to deteriorate without this treatment. In this case this patient had reports of depression which was not responding to treatment and required TMS treatment and medications changes including adding Bupropion and also continued to report craving for use and struggles with implementing coping skills which put him at moderate risk for relapse without this structured 3 day per week IOP treatment. The chart notes supported that he required this structured and supervised IOP treatment.

Notes reported that he had cravings for benzodiazepines and also Viibryd was increased due to depression. Notes reported that he had anxiety daily and struggled to manage symptoms due to not implementing positive coping strategies. He reported that he would like to work towards the development of positive coping skills to manage symptoms and address the relapse process. Notes reported that he showed limited progress and struggled with cravings, depression, and anxiety, was still isolating, struggling with grief, was not implementing positive coping strategies, and was at moderate risk for relapse due to lack of coping skills, isolating, and limited connection with the community. Notes reported that he had anxiety daily due to not implementing positive coping strategies and was thinking about using marijuana and needed to work towards developing positive coping skills. Notes reported that he stopped Viibryd and started TMS treatment due to depression and fatigue and Bupropion was added. He also took Buspirone and L-Methyl folate. It also was reported that his mother abuses stimulants, so he did not have a sober living environment if he were to go to there. It also was reported that he was not sure when he was leaving the sober living. He also reported depression.

Without this structured treatment it was likely that he was at risk for relapse and worsened depressive and anxiety symptoms. As a result, substance IOP treatment was medically necessary.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for intensive outpatient substance use treatment is overturned. Medical necessity is substantiated.