Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Substance Abuse
Treatment: Continued Partial Hospital Program Substance Use Disorder Rehabilitation Treatment
Continued Partial Hospital Program Substance Use Disorder Rehabilitation Treatment.
The determination is overturned in part.

The patient was admitted to a partial hospital program (PHP) level-of-care for substance use disorder treatment with moderate to severe use of cannabis and tobacco/nicotine class substances. The patient is diagnosed with co-occurring depressive and anxiety disorders best characterized as an unspecified depressive and anxiety disorder with associated symptoms of insomnia. The patient's substance use had its onset at age twenty and then escalated as the coronavirus 2019 (COVID-19) pandemic occurred with progression of the disease and decline in functioning. A precipitating and perpetuating factor was conflict within the family of origin and the symptoms of anxiety and depression that triggered his substance use. The patient had no prior substance use treatment and no history of blackouts or withdrawal seizures or delirium tremens. He had a trauma history due to a toxic home environment while growing up. He had no legal issues, but was selling marijuana to support his addiction with his use of up to five joints per day. His substance use included a past use of ketamine and oxycodone, but he denied current use of substances other than cannabis and tobacco.
His mental status examination at the time of admission was free of severe symptoms such as mania, thought disorder, psychosis, perceptual disturbance, or cognitive impairment. He presented with depression, anxiety, insomnia, and restlessness. He was generally cooperative and generally calm, but anxious at times during the interview. He had limited insight and impaired judgment and poor control of impulses due to the substance use. He reported cravings and anxiety that represented a high risk of relapse. He had insomnia with only 3 hours of total sleep time, as well as poor appetite, low energy and problems of volition.
The patient is married and employed in the family business. He has four children. The marriage is described as supportive. There was no family history of substance use disorder or mental disorder.
The patient presented for Partial Hospitalization Program (PHP) level substance-related treatment. He had the opportunity for participation in group, individual, psycho-educational and other therapies with focus on the development of coping skills while maintaining abstinence from substances of abuse. Life skills and other therapeutic interventions including motivational enhancement therapy (MET) were provided, as well as continued treatment with evidence-based therapies and wellness activities with meditation, yoga, relaxation techniques, mindfulness and EMDR (Eye Movement Desensitization and Reprocessing).
The patient made unsteady progress with the rehabilitation treatment. He had thoughts of leaving the program against medical advice (AMA) but remained in treatment. The patient had made modest progress, but still struggled with treatment. He had problems with motivation at the contemplative stage of change, and continued to have insomnia and anxiety. Gabapentin and doxepin were prescribed with adherence and tolerability. He continued to receive and participate in individual, group, and educational sessions with addition of work to develop a relapse prevention plan with identification of triggers, the development of sober supports, and involvement in 12-step recovery groups with peer support.
By the last week of treatment, the patient was noted to be more hopeful and optimistic and better engaged in treatment. His Patient Health Questionnaire (PHQ-9) assessment was at a 1 with mild depression and his anxiety and insomnia had improved with a positive outlook for the future. He was nearing a euthymic state with persistence family issues that were being addressed with family-focused sessions and continued wellness activities including exercise. Case management had developed a plan for step down with no complications during this time interval. He continued in Partial Hospitalization Program (PHP) level treatment and was discharged with recommendations for clinically appropriate aftercare.
The health plan documents including case notes, schedule of benefits and excerpts from the Summary Plan Description were reviewed, as well as the health plan's Administrative Policy for Behavioral Health Services. Appeal documents were reviewed, as submitted, with correspondence from the treatment facility. The health plan's rationale for the denial of authorization for continued coverage of the requested services was reviewed together with reference to and review of the American Society of Addiction Medicine (ASAM) Criteria and the American Academy of Clinical Psychiatrists Level of Care Utilization System (AACP LOCUS) Guidelines. This review is New York (NY) State mandated 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/Guidelines.
At issue is the medical necessity of Continued Partial Hospital Program Substance Use Disorder Rehabilitation Treatment.

The requested health service/treatment of Mental Health Partial Hospitalization Program was medically necessary for this patient in part.
The patient's PHP level services with the continued structure and monitoring of PHP level service for 25 days was necessary in order to effectively address anxiety and depression triggering his use of cannabis, to continually assess the risk for relapse, to develop a relapse prevention plan with motivational techniques and work on coping skills to remain engaged in a recovery process, to address family issues with a detailed psychosocial assessment, and consider other psychosocial issues pertinent to his substance use disorders including the need for sober supports, and develop a transition plan that would effectively prevent treatment failure. These treatment factors and clinical features did necessitate the continued structure and monitoring of a partial hospital setting while receiving substance abuse treatment with development of a discharge plan and determination of the clinically appropriate disposition. The patient could not have been effectively treated at a lower level of care for these dates of service consistent with ASAM Criteria and NY State LOCADTR 3.0 Criteria/Guidelines. However, the patient had reached a level of stability such that he was capable of continuing treatment with lower-level services in a less restrictive treatment.