Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Continued Intensive Outpatient Care
The insurer denied the Continued Intensive Outpatient Care
The denial is overturned. 

The patient is a male who presented as a step down for intensive outpatient program (IOP) level treatment for co-occurring disorders including severe alcohol use disorder, bipolar affective disorder and generalized anxiety disorder in the context of severe psychosocial stressors and trauma history with a diagnosis of post-traumatic stress disorder (PTSD). The patient has a history of using alcohol since adolescence with progression of the disease and escalating use resulting in his self-referral for treatment with detoxification and partial hospital program level services with step down to intensive outpatient program (IOP) level services. Thus, the patient's presentation for intensive outpatient program (IOP) treatment followed partial hospital program treatment and he had received detoxification treatment with immediate transfer for substance use disorder rehabilitation and dual diagnosis treatment of the co-occurring psychiatric disorders.

The patient presented with mood disturbance, anxiety and severe substance-related problems that had resulted in functional impairments and inability to maintain abstinence. He had no prior substance use disorder treatment. The patient provided no history of withdrawal seizures or delirium tremens. He was medically screened prior to intensive outpatient program (IOP) level treatment  with three day per week and three hours per day programming, as well as sober living and involvement in recovery groups, and intensive treatment of the mood, anxiety and trauma-related disorders.

The patient was admitted with step down for intensive outpatient program (IOP) treatment having had the detoxification and partial hospitalization program (PHP) level care. His clinical course progressed slowly without incident. However, he continued to display affective disturbance and reported intense craving during the initial weeks of intensive outpatient program treatment. While in intensive outpatient program level care, the patient's health plan changed with Medicare part A&B. The patient participated in intensive outpatient program (IOP) sessions including therapies with cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) techniques, and he was regularly attending 12-step recovery groups with plans for obtainment of a sponsor. He received medication assisted treatment with gabapentin for anxiety/post-acute withdrawal symptoms (PAWS). He was prescribed Prozac, Seroquel and trazodone with as needed (PRN) use of Vistaril. Vistaril and trazodone/Seroquel were effective in addressing symptoms of anxiety and insomnia. He also was participating actively in group and educational sessions with the goal of developing improved coping skills which were notably deficient. He gradually participated more actively in treatment with increasing levels of engagement despite persistent anxiety, craving and sleep disturbance that were present. He remained in the treatment program with subsequent step down to outpatient level care with plans for trauma recovery and eye movement desensitization and reprocessing (EMDR), as well as continued dual diagnosis treatment for the co-occurring disorders. He completed the program and was discharged with referrals and recommendations for clinically appropriate aftercare and consideration of a sober living environment (or supports) and continued participation in peer-supported recovery groups.

Reason for Denial was indicated on the basis of the plan's Behavioral Health Services administrative policy, and also with the indication by the health plan that the New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was no longer met for the intensive outpatient program  level care and dates of service under review.


The appeal documents reference the change in health care coverage with the addition of Medicare triggering the denial for continued intensive outpatient program (IOP) services, and as the primary reason for the denial, and the appeal asserts that the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool continued to support intensive outpatient program level care thus supporting the clinical judgment to have the patient remain at the intensive outpatient program level of care for the dates of service under review.

Yes, the proposed treatment, continued intensive outpatient substance use and dual diagnosis treatment, is medically necessary for this patient.
The requested benefit of continued intensive outpatient substance use treatment for the dates of service could not have been effectively provided at a lower level of care in this case scenario. The patient in this case presented with a mood and anxiety disturbance with trauma history and he was using large quantities of alcohol on a daily continuous basis with severe psychosocial stressors and functional impairments that did warrant the continued intensive outpatient program level structure, monitoring and services. The treatment for the co-occurring disorders diagnosed in this case could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission to the treatment program. Moreover, the patient's social environment was not conducive to lower level treatment, and the patient struggled with craving in the context of the mood disturbance and associated symptoms of anxiety with limited insight, impaired judgment and poor control of impulses.

Thus, the clinical features and treatment dimensions outlined in the American Society of Addiction Medicine (ASAM) Criteria did necessitate the continued structure of an intensive outpatient program level setting with intensive treatment, structure, supports, and safety monitoring. The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors and co-occurring psychiatric disorders do reflect a complicated clinical picture, and does support and the need for a safe and effective treatment setting, especially in regard to recent suicidal threats while using alcohol and the potential for high-risk behaviors while under the influence of alcohol. The documentation clearly indicated that the patient was at high risk for treatment failure if treatment were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, consistent with New York State instruction for medical necessity reviews including the appropriate application of the New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.

The requested benefit of continued intensive outpatient substance use disorder and dual diagnosis treatment is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The treatment of the patient's co-occurring mental health and substance use disorders could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care and the guidelines and scientific literature, referenced below, as well as meeting New York State instructions for this case review and the appropriate application of New York State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Guidelines and Criteria, asserted by the appeal.