Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Opioid use disorder. 
Treatment: Partial hospitalization mental health treatment. 

The insurer denied partial hospitalization mental health treatment.  The health plan's determination is upheld.

The patient is a male who presented for partial hospital program (PHP) treatment with diagnoses of opioid use disorder in partial remission, generalized anxiety disorder and major depressive disorder. The patient has a history of poly-substance use with Fentanyl as his drug of choice, and past use of other substances of abuse including marijuana, stimulants and benzodiazepines. His referral for PHP level care occurred after being administratively discharged from another treatment program for fighting with a peer. The patient has a history of multiple substance-related treatment episodes.
Mental status examination on admission to PHP level services was free of severe psychiatric symptoms including mania, psychosis, perceptual disturbance and cognitive impairment. The patient had residual symptoms of anxiety with normal (euthymic) mood and organized thoughts and clear speech. He had no suicidal or homicidal ideation and was generally motivated for treatment, although he was prone to lose interest in treatment. Insight was limited and judgment impaired with poor control of impulses by history.

During the course of PHP level treatment, the patient was participating actively in his rehabilitation treatment. He had no biomedical complications or severe withdrawal symptoms during his treatment. He was working on coping skills and a relapse prevention plan together with individual, group and other therapeutic activities that included psycho-education. The patient was discharged abruptly against medical advice with no explanation of plans by the patient. The subject under review was the medical necessity for the partial hospitalization mental health treatment level of care.

The health plan's determination is upheld.

The requested health service/treatment of partial hospitalization mental health treatment was not medically necessary for this patient.

The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that PHP level structure or services is medically necessary for a successful outcome in this case. In addition, there were no biomedical, psychiatric or general medical issues that warranted the PHP level of care.

Thus, the patient's substance use disorders and co-occurring disorders were amenable to treatment at a lower level of care in this case scenario.

The PHP level substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care. The patient was generally motivated and capable of effectively engaging and continuing his substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. Again, there were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted PHP level services and treatment. 

This answer is consistent with prevailing standards of professional practice, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, as well as the application of  Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines.