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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. For dimension 1, the patient had no signs of acute withdrawal from alcohol that required treatment at a higher level of care. The patient was admitted to IOP level of care on transfer from RTC after 30 days of treatment. The patients post-acute withdrawal symptoms were safely managed in a Level 3.1 treatment setting. For dimension 2, the patient is noted to have comorbid Lupus, which is treated with Plaquenil. The patient has biomedical problems that were stable and did not require medical or nurse monitoring. For dimension 3, the patients mental status was sufficient to permit participation in the therapeutic interventions provided at Level 3.1. The patients symptoms included severe cravings, guilt, passive suicidal ideation, and hopelessness, with a constellation of symptoms consistent with PTSD. The patients residual psychiatric symptoms include multiple relapses and treatment episodes with a history of rapid relapse. She was provided with imperative tools to deal with her emotions and engrained reactions that have historically triggered relapses. The patient required monitoring of her psychiatric symptoms concurrent with her alcohol use disorder given her anxiety and PTSD. For dimension 4, the patient was ready for change and cooperative enough to respond to Level 3.1 treatment. She required this level of care given her PTSD, her externalization of symptoms stemming from past abuse, and her known inability to succeed in a lower level of care. The patient acknowledged the existence of a psychiatric problem and her alcohol use disorder. She recognized the negative consequences, her dysfunctional behaviors, and their effect on her desire to change. The enrollee was sufficiently ready to change and cooperative enough to respond to treatment at Level 3.1.  For dimension 5, the patient has demonstrated relapse triggers and significant cravings. She also received dialectical behavior therapy (DBT) and individual therapy to deal with the complex interplay between her alcohol use, anxiety, and trauma. Toxicology screens revealed ethyl glucuronide was negative on admission, but was later positive in July 2018. Overall, the patient demonstrated limited coping skills to identify and address relapse triggers and urges. She was in imminent danger of relapse with dangerous behavioral consequences, and needed 24-hour structure to help her apply recovery and coping skills. For dimension 6, the patient lives with her spouse, who reportedly presented the patient with an ultimatum regarding her drinking, but the providers described him as enabling. The patient was living in an environment that is characterized by a substance use endemic that the patient was assessed as being unable to achieve or maintain recovery in a less intensive level of care. Accountability through monitoring of presence for ethyl glucuronide, in her urine, as accomplished through the Level 3.1 program was an additional deterrent to her using alcohol. The patient was able to cope for limited periods of time, outside the 24-hour structure of a Level 3.1 program in order to pursue community activities. Given these findings, the patient met the six ASAM dimensions for IOP services during the period under review. Therefore, the IOP services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine 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.