Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Partial Inpatient Substance Use Treatment.
The insurer denied the Partial Inpatient Substance Use Treatment.
The denial is overturned.

The patient is a adult male who presented as a step up for partial hospital program (PHP) level treatment for co-occurring disorders including severe alcohol use disorder and polysubstance use with opioids, stimulants, cannabis and cough syrup; bipolar affective disorder in depressed phase and generalized anxiety disorder in the context of severe psychosocial stressors and trauma history with a diagnosis of PTSD (post-traumatic stress disorder). The patient has a history of using his drugs of choice, alcohol and cough syrup, since adolescence with progression of the disease and escalating use resulting in multiple past treatment episodes with a history of leaving treatment against medical advice (AMA) and relapsing. His self-referral for PHP (partial hospital program) level treatment followed a relapse while in IOP (intensive outpatient program) level treatment with use of alcohol and cough syrup in the last two days of IOP (intensive outpatient program) treatment.

The patient presented with mood disturbance, anxiety and severe substance-related problems that had previously resulted in functional impairments and inability to maintain abstinence despite living in a sober house and attending 12-step recovery meetings. The patient provided no history of withdrawal seizures or delirium tremens, but reported frequent blackouts and psychosis when using substances, as well as high risk behavior, trading sex for drugs. He was medically screened prior to PHP (partial hospital program) level treatment beginning with five day per week and six hours per day programming, as well as sober living and involvement in recovery groups, and intensive treatment of the mood, anxiety and trauma-related disorders.

For the dates of service in question, the patient was participating actively in group and educational sessions with the goal of developing improved coping skills which were notably deficient. He gradually participated more actively in treatment with increasing levels of engagement despite persistent anxiety, craving and sleep disturbance that were present during the stay. He remained in the treatment program with subsequent step down to intensive outpatient (IOP) level care with plans for trauma recovery, as well as continued dual diagnosis treatment for the co-occurring disorders. He was discharged with referrals and recommendations for clinically appropriate aftercare and resumption of a sober living environment (or supports) and continued participation in peer-supported recovery groups.

The health plan denied coverage on the basis of the ASAM (American Society of Addiction Medicine) Criteria and medical necessity indicating that PHP (partial hospital program) level care was not met for the DOS (dates of service) under review. The denial determination indicated that the patient's treatment did not require PHP (partial hospital program) programming and that IOP (intensive outpatient program) level care was the appropriate level of care per ASAM (American Society of Addiction Medicine) Criteria.

The appeal documents reference the severity of the substance use disorders and clinical features and treatment history as the primary reason for the admission to PHP (partial hospital program) level care, and the appeal asserts that ASAM (American Society of Addiction Medicine) assessment supports the PHP (partial hospital program) level of care thus supporting the clinical judgment to have the patient step up to PHP (partial hospital program) level of care for the DOS (dates of service) under review. The appeal argued that the treatment plan was valid with respect to 5 day per week and 6 hours per day programming with the structure, monitoring and intensity of treatment for the duration of the stay.

Yes, the requested health service, PHP (partial hospitalization program) level substance use disorder and mental health treatment  is medically necessary in keeping with New York State instruction for this review.
The requested benefit of PHP (partial hospitalization program) substance use disorder and mental health services through discharge could not have been effectively provided with lower level services, and is a covered service and therefore medically necessary in keeping with prevailing standards of medical practice and the ASAM (American Society of Addiction Medicine) Criteria as indicated in the appeal and contrary to the denial determination.

The PHP (partial hospitalization program) level substance use disorder and mental health services through discharge for severe alcohol use disorder and co-occurring psychiatric disorders (bipolar depressive disorder and generalized anxiety disorder and trauma related symptoms) did require the step up with admission to PHP (partial hospitalization program) level services and the continued structure, frequency, and intensity of services provided with PHP (partial hospitalization program) level services thru discharge. The patient's history of substance abuse, limited insight, impaired judgment with high risk for relapse and history of high risk behaviors with blackouts, and persistent symptoms of anxiety with PAWS (post-acute-withdrawal syndrome)/craving does reflect the seriousness of the substance use disorder and the need for a safe and effective treatment episode with the continued structure and services provided with the PHP (partial hospitalization program) services, as well as addressing post-acute withdrawal symptoms with medication treatment with gabapentin and Remeron.

The patient had declined in functioning with severe psychosocial consequences due to the alcohol and drug use and co-occurring mental health issues; he continued to have substantial treatment issues that did require the admission and continued PHP (partial hospitalization program) level care for the time interval under review. The patient's stage of change was not sufficient to maintain abstinence without additional treatment with PHP (partial hospitalization program) substance use disorder services, as requested. The patient remained at high risk for relapse during the time interval under review-as noted. During the time interval under review, the patient was receiving essential intensive therapy to address the addictive behaviors and symptoms of anxiety and depression that were clearly serving to trigger the patient's substance abuse. Moreover, the patient was working with the treatment team to build additional sober supports while planning for his return to the community with sober living and IOP (intensive outpatient program) level care.

The clinical features and treatment dimensions in this case factored into the need for step up and continued intensive treatment until the development of a safe and clinically appropriate disposition was in place, and the patient was able to sustain recovery work. Thus, the standard of care and New York State LOCADTR (level of care for alcohol and drug treatment referral) Criteria and ASAM (American Society of Addiction Medicine) Criteria are met with regard to the requested benefit of the Admission and the Continued PHP (partial hospitalization program) substance use disorder program and mental health services in this case scenario. The step up to PHP (partial hospitalization program) level treatment provided for the completion of a solid and reasonable discharge plan that was medically necessary and included the development of a safe and clinically appropriate disposition with continued services to address the alcohol use disorder and the co-occurring disorders and psychosocial stressors in this case.

These answers are consistent with prevailing standards of care, and with the published guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, as well as New York State instruction for this review.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested benefit of PHP (partial hospitalization program) substance use disorder and dual diagnosis treatment is clinically appropriate, medically necessary and warranted, and should therefore be covered in this case scenario. The treatment of the patient's co-occurring mental health and substance use disorders could not have been safely or effectively provided with lower level services, as noted in the answer to question 2. Thus, the requested benefit should be covered in keeping with prevailing standards of care and the guidelines and scientific literature, referenced below, as well as NY (New York) State instructions for this case review and the appropriate application of NY (New York) State OASAS (New York Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Guidelines and Criteria.