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

Nature of Statutory Criteria/Case Summary: The patient was diagnosed with alcohol dependence and generalized anxiety disorder. The patient was initially treated in a detoxification program for 10 days for severe alcohol use. The patient was noted to drink 16 ounces of vodka daily and was admitted to an intensive outpatient program (IOP). The patient was reported to be attentive and engaged in group therapy. The records noted alcohol dependence and generalized anxiety disorder. She denied suicidal ideation and reported feeling better due to talking about her problems. The patient endorsed social isolation and substance use as behaviors that interfere with her quality of life. She also reported a stress dream about drinking. The patient was noted to be attentive, engaged, and more hopeful. The patient has requested reimbursement for intensive outpatient program (IOP) services. The Health Plan denied the request and reported the services at issue were not medically necessary for the treatment of this patient. The issue in this case is whether intensive outpatient program (IOP) services were medically necessary for the treatment of the patients medical condition. For acute intoxication and/or withdrawal potential, the patient was at minimal risk of severe withdrawal due to the recent completion of a detoxification program. For biomedical conditions/complications, the patient did not have medical conditions or complications. For emotional/behavioral/cognitive conditions/complications, the patient was diagnosed with generalized anxiety disorder. For readiness to change, the patient had variable treatment engagement and required a structured program, as she had previously been unable to engage in treatment for years. For relapse/continued use/continued problem potential, the patient had a high likelihood for relapse without close monitoring and support. For recovery environment, the patient had an unsupportive environment as her family did not participate in her treatment. In this case, the patients relapse and safety risk factors include her tendency to isolate and comorbid anxiety. An IOP treatment, which encompasses services that are capable of meeting the complex needs of patients with addiction and co-occurring conditions, such as her anxiety disorder. The patient was reported to be engaged in treatment with gains including reduced anxiety and more hope. The medical evidence supports the services received in this clinical setting. Therefore, intensive outpatient program (IOP) services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services were 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 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.