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

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensive outpatient program (IOP) services for treatment of the enrollees major depressive disorder, obsessive compulsive disorder (OCD), generalized anxiety disorder, and attention deficit hyperactivity disorder (ADHD).  Findings: The physician reviewer found that this case incorporates every element of the biopsychosocial-cultural model of conceptualization and represents a patient burdened with prominent psychiatric impairment complicated by a co-dependent relationship with his mother. In accordance with modern psychiatric practice, the patient had first pursued treatment in the outpatient setting during the episode of illness. He failed that level of care and enrolled in IOP treatment. Shifting the frequency of therapy is common for individuals with severe OCD and consistent with the American Psychiatric Association (APA) clinical practice guideline. Additionally, the diagnosis of clinical depression accompanies this patients OCD and generalized anxiety. This is of particular relevance since it has been well-established in both clinical practice and the medical literature, such as the definitive Sequenced Treatment Alternatives to Relieve Depression (STAR-D) study, that anxiety-ridden mood disorders are known to be difficult to treat. This patient had significant mood symptoms with suicidality. He had poor self-esteem and difficulty regulating emotions. He had intrusive thoughts of harming others. In the absence of adequate treatment, the confluence of self-perceptions, clinical symptoms and cognitive schemas placed the patient at risk for an untoward outcome and potentially harming himself and/or others. As such, a premature discharge would likely result in undue patient morbidity and prompt re-admission, possibly to a higher level of care. During the course of therapy, the patient improved with active treatment. He was noted to have fewer obsessions and mood symptoms while his anxiety had decreased. Although the programmatic goals of following through with daily responsibilities and enhancing strategies to overcome obsessive thoughts are difficult to quantify, social skills training and community-based supportive interventions, which were noted to be limited outside of the IOP program, facilitate a gradual and seamless transition to the outpatient setting and prevent a more serious episode of illness. Thus, the providers request for an additional 12 days of IOP programming twice per week to consolidate treatment gains while bolstering comprehensive outpatient recovery-oriented aftercare is safe and appropriate in this clinical setting. In sum, 12 sessions of IOP, at the frequency of two visits per week, forward were and are medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that a portion of the services at issue were and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.