Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Substance Abuse Outpatient. 

The insurer denied the intensive outpatient substance use treatment. The denial is overturned, in whole. 

The patient is a male referred by his outpatient mental health providers for residential mental health treatment to address behavioral disturbances in the context of mood and attention disorders and co-occurring substance use disorder associated with impaired functioning and problematic behaviors. The patient was diagnosed with longstanding severe and recurrent major depressive disorder; attention deficit hyperactivity disorder (ADHD); and, severe co-occurring substance use disorders with severe cocaine, hallucinogen, tobacco and cannabis use disorders including the use of crack cocaine and over-the-counter medications-Benadryl and dextromethorphan (DXM). He was also using other substances of abuse intermittently including alcohol, amphetamines, benzodiazepines, opioids (heroin) and inhalants. His drugs of choice were used in a combination resulting in states of intoxication and overdoses and erratic behavior. 

The patient has a history of lengthy outpatient and more restrictive mental health and substance use disorder treatments without sustained benefit, as well as acute inpatient level psychiatric treatment for suicidal and self-harming behaviors as well as emergency treatment for at least two potentially lethal overdoses. There has been a suicidal behavior and inappropriate behaviors with associated impulse control problems and frequent bouts of intoxication associated with erratic behavior. 

Initial evaluation upon admission Intensive Outpatient Program [IOP] services revealed a mental status examination that was free of severe psychiatric symptoms such as psychosis, thought disorder, severe cognitive impairment or active suicidal ideation. The patient was cooperative with a guarded and paranoid stance in the context of oppositional behaviors and disregard for rules/authority. Mood was dysphoric and affect was anxious together with the history of emotional dysregulation and problematic behaviors that included academic failure due to behavioral issues, and behaviors that were self-destructive or reflective of severe mood disturbance and self-treatment with substances of abuse. The patient's anxiety included social anxiety associated with problematic interpersonal functioning. He was described as depressed with anxious demeanor and passive suicidal thoughts that were persistent. Insight was limited and judgment impaired with poor control of impulses. Moreover, his executive functioning was deficient including organizing, sequencing, problem solving and decision-making. 

Eventually the patient was able to fully engage in treatment and was noted to gradually gain insight and showed improved control of impulses. He remained dysphoric with anxiety that included social anxiety, apprehension, nervousness, tension, sleep disruptions, irritability and excessive worry. Family-focused sessions were beginning to gain traction and served to facilitate steady improvement that was modest. The patient was treatment plan compliant and had started to work earnestly with regard to behavioral interventions and other evidence-base therapies while participating in milieu and activity therapies designed to build self-confidence and life skills. The patient was noted to increasingly be more at ease with peers and staff, and better engaged with group and individual sessions including the incorporation of better coping skills. He had frequent family focused sessions to address issues within the family constellation and to prepare for a step down to lower level care. He consistently denied suicidal ideation or urges to self-harm during the last weeks of the treatment episode. He achieved mood regulation and became better motivated to participate in treatment including involvement in peer support groups and other therapeutic interventions to support abstinence from the multiple substances of abuse. 

After great deliberations, the patient was subsequently referred for clinically appropriate aftercare. The correspondence and case summary indicates that he had steadily participated in mental health services with better functioning and improved mood during the last three weeks of his inpatient residential stay-IOP treatment with boarding. He was noted to be at risk for regression upon return home prompting the recommendations for continued intensive mental health and substance use disorder treatment. Again, the treatment team recommendations for clinically appropriate aftercare were to have continued involvement with intensive and structured therapy, as well as psychiatric aftercare and other interventions to support abstinence and a recovery from severe substance use disorders. He was discharged with immediate step down for the extended care and lower level mental health and substance use disorder services and treatment. 

The subject under review is the medical necessity for the intensive outpatient substance use treatment. 

The requested health service/treatment of intensive outpatient substance use treatment is medically necessary for this patient. 

The patient's admission and continued IOP level treatment through discharge is reasonable and in the best interest of the patient; he continued to display clinical features and symptoms that necessitated the admission and the continued IOP level services as he struggled to engage in treatment and had intermittent bouts of affective instability that did warrant the IOP level structure and monitoring with active treatment. He had a history of treatment failure with lower level services and had recently displayed significant and problematic behaviors with maladaptive coping, emotional regulation problems, distress problems, interpersonal functioning problems and day-to-day functioning problems that included academic failure in the context of severe mood and substance use disorders complicated by ADHD. He continued to represent a safety risk and relapse risk and could not have been effectively managed in a less restrictive treatment environment through discharge. Moreover, the monitoring, structure and intensity of services were medically necessary in keeping with prevailing standards of medical practice and 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 Guidelines, referenced below.