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

An enrollee has requested reimbursement for the intensive outpatient program services provided from 1/03/18 through 1/05/18. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. In this clinical setting, the services at issue were medically necessary and treatment efforts in a less restrictive setting at that time would have been inadequate for this patient.  In general, the determination of the appropriate level of care for patients with addictive disorders complicated by depression and multiple medical problems is a challenging endeavor. Assisting with this process, the American Society of Addiction Medicine recommends placement based on a complex individual assessment. Therefore, in clinical practice, the placement decision is the last step in a multi-dimensional assessment that guides the variety and intensity of services needed in an individualized treatment plan. There is substantial research that indicates patients with greater substance use severity and co-occurring problems, such as psychiatric disorders and housing problems will do better in increased intensive forms of treatment. Further, the American Psychiatric Publishing Textbook of Substance Abuse Treatment suggests improved functionality and decreased mortality associated with individuals who complete intensive outpatient programming. The graduates used fewer psychiatric inpatient bed days in comparison with both program non-completers and their own prior use. At three years, graduates had lower death rates. In this case, the patient had a serious addiction to alcohol, which contributed to impairment across multiple functional domains. The patient was blacking out and operating a motor vehicle while drinking. The patient was having occupational problems and family strain due to his drinking. The patient had a co-occurring psychiatric illness. The patients aftercare was not finalized by 1/3/18. The patient was still working through internal and externa stressors. During the disputed timeframe, the patient attended, participated, and benefitted from the intensive outpatient services. The treatment was reasonably expected to improve the patients condition and prevent a worsening episode of illness or relapse, which in turn would have more than likely placed the patient and others at risk and required a more intensive treatment setting. It is more than likely that in the absence of sustained sobriety, this patients chronic medical comorbidities would demand greater clinical attention. In sum, the intensive outpatient program services provided from 1/03/18 through 1/05/18 were medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are 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 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.