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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting reimbursement for intensive outpatient program (IOP) services.  The enrollee received and participated in psychiatric assessment, group therapy, individual counseling, medication reviews/monitoring, psycho-social assessment, life skills, and psycho-educational group. By discharge, she reported a strong commitment to staying sober and attended 12-step meetings regularly. During her admission, the enrollee continued her outpatient medications of Seroquel as needed for sleep, Buspirone and Lexapro. For risk of harm, the enrollees score is 3, due to no active suicidal/homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior exists. For functional status, the enrollees score is 2, due to the enrollee developing minor but consistent difficulties in social role functioning and meeting obligations such as difficulty fulfilling parental responsibilities or performing at expected level in work or school, but maintaining the ability to continue in those roles. For comorbidity, the enrollees score is 3, due to significant psychiatric symptoms and signs are present which are themselves somewhat debilitating, and which interact with and have an adverse affect on the course and severity of any co-existing substance use disorder. For recovery environment level of stress, the enrollees score is 2, due to the presence of some ongoing or intermittent interpersonal conflict, alienation, or other difficulties; a transition that requires adjustment such as change in household members or a new job or school, and circumstances causing some distress; such as a close friend leaving town, conflict in or near current habitation, or concern about maintaining material well being. The potential for exposure to alcohol and/or drug use exists. For recovery environment level of support, the enrollees score is 3, due to the usual sources of support may be somewhat ambivalent, alienated, difficult to access, or have a limited amount of resources they are willing or able to offer when needed. For treatment and recovery history, the enrollees score is 3, due to previous or current treatment has not achieved complete remission of symptoms or optimal control of symptoms. For engagement and recovery status, the enrollees score is 2, due to significant understanding and acceptance of illness and attempts to understand its affect on function. The enrollee demonstrates willingness to change. The enrollee engages in treatment in a positive manner, is capable of developing trusting relationships, and will use available resources independently when necessary. The enrollee shows some recognition of her personal role in recovery and accepts some responsibility for it. The enrollees composite LOCUS score is 18, which correlates with high intensity community based treatment. Medical evidence supports the services at issue in this clinical setting.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical