Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polysubstance use disorder
Treatment: Substance use disorder services
The insurer denied substance use disorder services.
The determination is overturned.

The patient was admitted for partial hospital program (PHP) level services for continued treatment of polysubstance use disorder (opioid, cannabis and tobacco), and co-occurring psychiatric disorders including generalized anxiety disorder, attention deficit hyperactivity disorder (ADHD) and other obsessive-compulsive related disorder. The patient has a history of escalating substance use; he reported daily of use of opioids (heroin and oxycodone) in large quantities and use of cannabis (marijuana). He had a binge pattern of use; daily use of opioids; and, he reported use and experimentation with other substances of abuse. He was using tobacco on a daily basis. There was conflict in the home due to his substance use including a decline in functioning and high-risk behaviors that included multiple inadvertent overdoses requiring emergency medical services, as well as coma for several days. The patient's referral for substance use disorder and mental health treatment was prompted by his continued use of substances and complications of the psychiatric disorders together with failure to achieve a sustained response to treatment at lower levels of care characterized by a chronic relapsing course.
There were no acute general medical issues in this case, and physical examination and laboratory assessments were normal or unremarkable. He had medications for the psychiatric disorders including Paxil, Buspar and Vyvanse, and he had received Suboxone.
Mental status examination included casual dress, cooperative but guarded stance, and, motor agitation/fidgeting. His speech was clear and fluent with normal tone and volume. Thoughts were produced in a linear fashion and were goal direct. The patient did not have evidence for mania, psychosis, cognitive impairment, or homicidal ideation. His mood was depressed with anxiety and irritability. He reported low interest with anhedonia, sleep disturbance and obsessive-compulsive disorder (OCD)-related symptoms. His Insight was limited and judgment impaired due to the substance use disorder, and the patient had poor control of impulses with craving for opioids.
The patient was poorly motivated to engage in rehabilitation treatment that prompted his treatment with PHP structure and use of a 24-hour sober living environment with supervision and random drug screens. He had family support from his family with whom he lived. There were no legal issues in this case. The patient was unemployed and had dropped out of school. Stressors included primary support, occupational, social environment (peers), and, other psychosocial domains with severe functional impairments.
The patient was admitted to partial hospital program (PHP) level services with a comprehensive evaluation and treatment plan. The treatment provided included individual and group counseling sessions, education, and other interventions to support a recovery effort including participation in age-appropriate recovery groups focusing on relapse prevention and development of life skills and better coping.
The patient was superficially cooperative during the initial PHP stay. His involvement in groups was appropriate. However, he remained anxious and depressed with irritability, anhedonia and limited insight impacting his stage of change. He participated in groups and individual sessions, as well as educational sessions and continued medication to address mood and anxiety with the use of Vyvanse for ADHD. Activity therapies were provided to improve life skills and healthy living.
He made incremental improvement with regard to mood and anxiety such that he was better able to participate in treatment for the co-occurring substance use disorders and mood disorder. His Suboxone was tapered.
The patient worked on the development of better coping skills with regard to emotional regulation and control of impulses, and with regard to distress tolerance (modified DBT). His affect was more stable though he remained at high risk for relapse reporting anxiety at 5/10 and depression at 3/10. He had begun working on a relapse prevention plan with identification of triggers. The treatment team was planning to have the patient proceed to intensive outpatient program (IOP) level services, when ready in order to provide continued intensive "dual diagnosis" treatment and safety monitoring, as well as medication management, as noted. He insight and judgment were only fair with a guarded to fair prognosis and risk for relapse that was significant. He was able to complete PHP level treatment with discharge.
The health plan documents, appeal documents, and correspondence were reviewed, as well as the health plan's certificate of coverage and rationale for the denial . This is a New York State review with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria, also reviewed.
The issue under review is Continued Partial Hospitalization Substance Use Disorders and Mental Health Treatment.
The requested health service/treatment of substance use disorder services is medically necessary for this patient.
The patient could not have been safely or effectively managed with lower level services during the time frame under review. The patient had risk for relapse that warranted PHP level services with boarding, as provided in this case. The continued PHP level services were provided with a treatment plan that was reasonable, clinically appropriate and necessary in keeping with prevailing standards of medical practice for the conditions under treatment in this case. The patient had demonstrated that he needed the structure and monitoring and intensity of treatment provided with PHP level services.
The application of ASAM Criteria and NY State LOCADTR Criteria support the expert opinion provided in this case. The patient's documentation is replete with evaluations reflecting high risk for relapse, affective instability, poor control of impulses in the context of impaired judgment, and and anxiety and attentional disturbance with history of multiple inadvertent overdoses and high-risk use of substances in the context of co-occurring psychiatric disorders.
Therefore, the requested benefit of continued PHP substance abuse rehabilitation services and mental health treatment through discharge and step down to IOP level services was medically necessary in order to manage the co-morbid psychiatric conditions; in order to address the patient's lack of awareness of the seriousness of the substance use disorders (multiple substances with large quantity and frequent use); in order to continue psycho-education and evidence-based psychosocial interventions; in order to address the social environment and severe psychosocial stressors; and, in order to work on relapse prevention skills that are necessary in building/working toward the development of a sober support system and continued recovery efforts with community providers and the patient's family. None of this therapeutic work could have been effectively provided for this patient at a lower level of care, especially in view of the multiple, complicating factors in this case. These clinical factors and treatment dimensions are the reason that the patient could not have been effectively managed at a lower level of care for the time frame under review.
This answer is consistent with prevailing standards of medical practice and is in keeping with ASAM and NY State LOCADTR Criteria, as well as the published guidelines and scientific literature, referenced below.