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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for the recommended intensive outpatient program (IOP) level of care.  Findings:  The physician reviewer found that the patient has also requested authorization and coverage for weekly individual therapy once the IOP services are completed, or beginning immediately if IOP services are deemed not medically necessary. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation does not support the medical necessity of the requested services. The records consist of mainly telephonic communication. It does not appear that the patient has been in consistent outpatient therapy over the past several months. The most recent psychotherapy progress notes indicated a recommendation for outpatient therapy at an interval of approximately once every two to three weeks. However, there was no recommendation for IOP programming in the treating therapists progress notes. Most recent progress notes indicate that the patient was exhibiting a euthymic mood and was not expressing suicidal or homicidal ideation. The progress notes further indicated that the patient has had relational problems in the recent past. The patient reported a plan to engage in couples therapy, which the therapist both supported and recommended. The records indicate that the patient has a diagnosis of borderline personality disorder and as had several suicide attempts or suicidal ideation episodes over the last several years. A randomized trial conducted by McMain and colleagues noted that suicide ideation and suicidal behaviors in patients with borderline personality disorder indicated that outpatient weekly treatment is effective for reduction of overall symptoms. The study further states that these results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder. Linehan and colleagues conducted a two-year randomized controlled trial and follow-up study regarding the effectiveness of dialectical behavior therapy, which states  that is appears to be uniquely effective in reducing suicide attempts.  According to Cottraux and colleagues, the effectiveness of another outpatient treatment, cognitive treatment therapy, which is used on a non-IOP basis, retained the patients in therapy longer, showed earlier positive effects on hopelessness and impulsivity, and demonstrated better long-term outcomes on global measures of improvement. The records do not indicate that the patient has had regular outpatient treatment or evidence-based treatment on a regular basis. However, the records submitted for review did not indicate that this patient required treatment on an intensive outpatient program (IOP) level of care. There is no indication of any regular treatment on an outpatient level or other serious symptoms that warrant intensive treatment. More importantly, this patient may benefit from outpatient treatment for mental illness. It appears that weekly outpatient therapy is appropriate beginning immediately given that IOP services are deemed not medically necessary. In summary, the recommended intensive outpatient program (IOP) level of care is not medically necessary for treatment of this patient. The recommended weekly individual therapy once the IOP services are completed, or beginning immediately if IOP services are deemed not medically necessary, are medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services, specifically, intensive outpatient (IOP) services are not medically necessary for the treatment of the patients medical condition. A portion of the requested services, specifically, weekly individual therapy are medically necessary for the 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.