Appeal type: Medical necessity
Decision: Overturned

This is a patient who referred for an intensive outpatient program (IOP) mental health treatment to address behavioral disturbances in the context of mood, anxiety, and co-occurring substance use disorders associated with impaired functioning and aggressive and violent behavior. The patient was diagnosed with moderately severe and recurrent depressive disorder; persistent depressive disorder; generalized or unspecified anxiety disorder and, moderately severe substance use disorders with cannabis, as well as recreational use of other substances of abuse including alcohol and hallucinogens. Additionally, the patient was diagnosed with attention deficit hyperactivity disorder (ADHD) or executive dysfunction that contributed to his difficulties with emotional regulation and anger/irritability.
The patient has longstanding issues with self-esteem, confidence, and relationship problems together with stressors within the primary support, educational and social environment domains; the patient has been in past treatment settings with continued symptoms of depression, anxiety and anger related symptoms together with a history of impulsive aggression and verbal violence toward family members and destruction of property, social withdrawal, and mood instability associated with substance use with daily continuous use of cannabis and intermittent use of other substances of abuse, as noted. The patient was referred to IOP treatment after being administratively discharged from a Wilderness Program (outdoor behavioral health program) in order to address the problematic behaviors and core symptoms of depression, anxiety and relationship/family problems including parent-child relational problems and his lack of motivation and the moderately severe substance use disorder with cannabis.
The patient has a history of outpatient treatments without sustained benefit. There have been violent and aggressive behaviors related to anger and impulse control problems. The patient has conflict with parents that did include lack of motivation and problematic behavioral disruptions that included violent behavior and the abuse of cannabis and other substances.
Initial evaluation upon admission revealed a mental status examination that was free of severe psychiatric symptoms such as psychosis, thought disorder, severe cognitive impairment or active suicidal ideation. Mood was dysphoric and irritable, and, affect was anxious together with a history of problematic behaviors that included impulsive aggression/anger and conflict with parents, and other behaviors that were self-destructive or reflective of severe mood disturbance including social withdrawal and self-treatment with substances of abuse. The patient's anxiety and anger were associated with problematic interpersonal functioning. He was described as depressed with anxious demeanor, but superficially cooperative and calm during the assessment. Insight was limited and judgment impaired with poor control of impulses.
The patient had no acute general medical conditions. The patient is supported in his treatment effort by family. He is a college student and is single.
The patient was referred and admitted and underwent a comprehensive evaluation with treatment planning that included therapeutic interventions to improve coping skills and self-esteem, as well as cognitive behavior therapy to address the mood and anxiety disorder. The treatment plan included the goals of improved coping; breaking the cycle of self-destructive behaviors including anger issues and impulsive aggression; and the development of healthy relationships and functioning.
The health plan's determination is overturned.
In this case scenario, The patient's treatment is reasonable and in the best interest of the patient; he continued to display clinical features and symptoms that necessitated varying level services including the step back down to intensive outpatient level services up until the time of discharge , as he struggled to engage in treatment and had intermittent bouts of affective instability that did require the requested structure and monitoring with active treatment.
The patient has a history of treatment failure with lower level services prior to admission to the IOP program and had recently displayed significant oppositional/aggressive behaviors with maladaptive coping, emotional regulation problems, distress problems, interpersonal functioning problems and day-to-day functioning program in the context of severe mood and anxiety disorders complicated by moderately severe substance use disorder. He continued to represent a safety risk, and could not have been effectively managed in a less restrictive treatment environment during the dates of service provided. These answers are consistent with the scientific literature and guidelines, referenced below, as well as prevailing standards of professional practice, and these answers are consistent 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.