Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.
Treatment: Continued intensive outpatient substance use treatment.
The insurer denied continued intensive outpatient substance use treatment.
The denial is Overturned.

The patient is an adolescent female who was admitted for intensive outpatient program (IOP) level treatment as a step down from residential level treatment. The patient was receiving treatment for sedative-hypnotic-anxiolytic (benzodiazepine), cannabis (marijuana), and alcohol use disorders. She was diagnosed with unspecified depressive disorder with associated symptoms of anxiety that served to trigger her substance use. The patient's alcohol and cannabis and sedative-hypnotic-anxiolytic substance-related disorders were severe with daily continuous use of Xanax together with prescribed Klonopin and use of marijuana up to four times per week with intermittent binge drinking of one-third bottle at a time. The patient's substance use started at adolescents with escalating use in the context of high-risk behaviors including impulsive aggression and self-harm. She had been suspended from school multiple times and had been hospitalized to address the problematic behaviors occurring while intoxicated. 

The requested substance user treatment could not have been effectively provided at a lower level of care in this case scenario. The patient in this case presented with a co-occurring mood disturbance with associated symptoms of anxiety and use of large quantities of drugs and alcohol with severe psychosocial stressors and functional impairments that did warrant the admission and the continued IOP level structure, monitoring and services. The patient's social environment was not conducive to lower level treatment as peers were using substances of abuse and the patient was not sufficiently motivated to maintain abstinence without the continued IOP structure. And, the patient 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, the clinical features and treatment dimensions in this case did warrant the continued structure of an IOP 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 co-occurring psychiatric disorder do reflect a complicated clinical picture, and does support and the need for a safe and effective treatment setting, especially in regard to the history of school suspensions and aggressive behaviors and the potential for high risk behaviors while under the influence of alcohol and drugs. 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, ASAM Criteria, and the scientific literature, referenced below, and, this answer is consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria/Guidelines.