Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive outpatient program (IOP) treatment with specific services including specialized treatment for co-occurring psychiatric and substance abuse disorders, individual therapy sessions, support on the weekends, 16 available hours of groups weekly, services with licensed therapists (not non-licensed intern therapists), family support sessions, clinical staff that is available 24-hours per day in the event of a crisis, staff that is equipped to refer an individual to emergency services and support of the family in the event of a crisis, large peer group meetings to assist in expanding social and emotional resources, sober fellowship activities, Alcoholics Anonymous (AA) meetings, and strict monitoring of social activities by eliminating social media use and eliminating contact with old friends engaging in drug use and/or other risky behaviors. Findings:  The physician reviewer found that based on the available documentation, the requested IOP treatment with specific medical services is medically necessary for treatment of this patients behavioral health condition. Patients with dual diagnosis require both substance abuse intervention and appropriate individual psychotherapy and when possible, both conditions should be treated at the same time. Large group therapy and strict monitoring of social activities to improve relapse prevention and to avoid returning to previous social actions from which substance abuse often arises are indicated for this patient. The patient meets the criteria for generalized anxiety disorder and there is evidence of emerging depression as well. In adolescents, both of these conditions are best treated with psychotherapy as well as possible medication. Given these findings, the requested IOP treatment with specific services including specialized treatment for co-occurring psychiatric and substance abuse disorders, individual therapy sessions, support on the weekends, 16 available hours of groups weekly, services with licensed therapists (not non-licensed intern therapists), family support sessions, clinical staff that is available 24-hours per day in the event of a crisis, staff that is equipped to refer an individual to emergency services and support of the family in the event of a crisis, large peer group meetings to assist in expanding social and emotional resources, sober fellowship activities, AA meetings, and strict monitoring of social activities by eliminating social media use and eliminating contact with old friends engaging in drug use and/or other risky behaviors are supported as medically necessary. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.