Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder
Treatment: Partial Hospital Substance Use Disorders Treatment with diagnosis code of F12.20 (cannabis dependence, uncomplicated)
The insurer denied coverage for the Partial Hospital Substance Use Disorders Treatment with diagnosis code of F12.20 (cannabis dependence, uncomplicated).
The denial is overturned. 

This is a male patient who was admitted to a substance partial hospital program after being transferred from a residential treatment and past detoxification treatment. The patient reportedly was using cannabis, opiates, and alcohol. The patient reported a history of driving under the influence (DUI) and also selling drugs and putting himself in unsafe positions; the patient had legal issues including possession charges. He reportedly had multiple past substance and mental health treatment episodes and still could not maintain abstinence. The patient reportedly was a victim of trauma. The patient had past history of suicide attempts by overdose and past hospitalizations. The patient had depressive symptoms including depressed mood and suicidal ideation. The patient reportedly also had flashbacks, and eating disorder symptoms including restricting of food intake, binging and purging. The patient's psychiatric diagnoses included Cannabis Use Disorder, Major Depressive Disorder, Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder, and Borderline Personality Disorder. The patient was living with his family and it was reported that his mother and his brother were using alcohol and cannabis. In this substance partial hospital program, the patient's treatment included individual, group, and family therapy. He was treated and discharged after months of treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that partial hospitalization programs can provide an intensive, structured treatment experience for individuals with substance use disorders who require more services than those generally available in traditional outpatient settings. In this case, this patient was in need of at least this structured and supervised treatment with multimodal treatment. He was considered a high risk patient who could not maintain abstinence despite past multiple treatment episodes, and he reportedly put himself and others at risk due to his substance use. He needed to improve his coping skills, identification of triggers, relapse prevention skills, communication and boundaries, interpersonal relations, self-esteem, impulse control, decision making, maintain safety, and better identify and correct irrational and negative thinking. 

As per review of the medical chart, notes support that this patient continued to struggle and required at least this level of care in this structured and supervised treatment with multimodal treatment as he needed to further progress to try to better maintain abstinence and safety. It was reported that this treatment was considered partial hospital program treatment as the patient was unsupervised overnight and stayed in the community which was a different location from his clinical services so he was able to try to adapt and function more independently in the community while still being treated during the day clinically. The chart notes support the need for at least substance partial hospital program as the patient was at high risk for harm to self and others due to his multiple significant comorbidities and substance use. Thus, substance partial hospital program is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the Partial Hospital Substance Use Disorders Treatment with diagnosis code of F12.20 (cannabis dependence, uncomplicated) should be overturned.