Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse, bipolar depression, eating
disorder.
Treatment: Partial Hospitalization Substance Abuse Treatment.
The insurer denied the Partial Hospitalization Substance Abuse Treatment.
The denial is overturned. 

The patient is an emerging adult female who presented for partial hospital program (PHP) level treatment for co-occurring disorders including substance use disorders with stimulant, alcohol and cannabis class substances of abuse, and psychiatric diagnoses of a mood disorder (bipolar depression), eating disorder (anorexia nervosa, restricting and binge-purge types) and generalized anxiety disorder with panic attacks. The patient has a history of escalating use of alcohol on a continuous daily basis with up to 16 shots of vodka together with one or two grams of cannabis/marijuana every three days, and, intermittent use of Adderall. 

The patient's presentation for partial hospital program treatment followed a serious overdose of alcohol requiring inpatient hospitalization which had occurred while in transit to the treatment facility. She had a history of severe eating disorder with active symptoms for two years while using alcohol and cannabis, and the mood and anxiety disorders occurring in the context of severe psychosocial stressors. She had family stress related to the substance use and other psychosocial stressors with relational problems characterized by cluster B personality traits that included antisocial, borderline and narcissistic personality features. She presented with mood disturbance with irritability, anxiety with panic, and, severe substance-related problems that had resulted in functional impairments and inability to work or maintain abstinence despite several treatment episodes at varying levels of care. The prior substance use disorder and dual diagnosis treatment had failed to result in sustained sobriety or involvement in a recovery process. At the time of presentation, the patient was also reporting worsening symptoms of depression and anxiety with sadness and anxiety and appetite disturbance. She was taking no prescribed medications other than Keppra that had been prescribed while hospitalized for alcohol poisoning. Additionally, the patient had a pattern of interrupting substance-related treatments reflecting poor impulse control and a lack of insight or motivation to change.

The patient was admitted for treatment. Her clinical course progressed slowly without incident. However, she continued to display affective disturbance and reported ongoing symptoms of anxiety with limited insight and high risk for relapse.  The patient was noted to display mood disturbance and was offered medication to address the mood lability in the context of irritable dysphoria and persistent anxiety. Though she refused mood stabilizer and medication assisted treatment, she received vitamin supplements, nicotine replacement therapy and comfort medications. 

The patient engaged in evidence-based psychosocial treatments that included group and educational sessions and anger management with the goal of developing improved coping skills. She gradually participated in treatment with increasing levels of engagement despite persistent anxiety and sleep disturbance. Family focused sessions and involvement in 12-step recovery meetings were provided, as well as activities to promote healthy living and better coping skills. 

Yes, the proposed treatment was medically necessary for this patient.
The requested benefit of partial hospitalization mental health treatment could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case presented with a severe substance use and co-occurring mood and anxiety disturbance with history of an eating disorder and escalating use of alcohol on a daily continuous basis together with cannabis and with severe psychosocial stressors and functional impairments that did warrant partial hospital program (PHP) level structure, monitoring and services. Moreover, the patient's social environment was not conducive to lower-level treatment, and the patient struggled with poor insight and impulse control in the context of the mood disturbance associated with maladaptive coping and cluster B personality traits with impaired judgment and the clinical feature of poor control of impulses.

Thus, the clinical features and treatment dimensions in this case did necessitate the structure of a partial hospital program (PHP) level setting with intensive treatment, structure, supports, and safety monitoring. The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors and functional impairments and co-occurring psychiatric disorders do reflect a complicated clinical picture, and does support the need for a safe and effective treatment setting, especially in regard to recent high risk behaviors. The documentation clearly indicated that the patient was at high risk for treatment failure if 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, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, consistent with New York State instruction for medical necessity reviews including the appropriate 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.

The requested benefit of partial hospitalization mental health treatment for the dates of service under review was clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The treatment of the patient's co-occurring mental health and substance use disorders could not have been safely or effectively provided with lower-level services, as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care and the guidelines and scientific literature, referenced below, as well as the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria and American Society of Addiction Medicine (ASAM) Criteria and Level of Care Utilization System (LOCUS) Guidelines-referenced below.