Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued Partial Hospitalization Substance Use Treatment 
The insurer denied the Continued Partial Hospitalization Substance Use Treatment. The denial is overturned.
The Continued Partial Hospitalization Substance Use Treatment was medically necessary for this patient in order to effectively address the continuing clinical needs for rehabilitation treatment of severe substance use disorders with evidence-based psychosocial treatments and medication assisted treatment with gabapentin and Wellbutrin, and to work toward relapse prevention; in order to address the patient's lack of awareness of the seriousness of her illnesses with psycho-education and recovery groups; and in order to address issues within the social environment including an appropriate disposition with sober supports, especially in working with the patient's clinical providers in developing a clinically appropriate disposition; and in order to work on coping skills that will be necessary in building a sober support system and continued recovery efforts with community providers and engagement with 12-step recovery groups and a sponsor. The patient was noted to be in the early stage of change with the need for medication assisted treatment, especially in view of ongoing cravings and persistent post-acute withdrawal symptoms. Wellbutrin was used for treatment of the co-occurring mood disorder combined with Trileptal. The patient's continued struggle with mood disturbance and severe psychosocial stressors warranted the continued PHP level structure and monitoring to assure abstinence while working on the development of relapse prevention plan and coping skills that were critical in this case together with necessary gains with insight that facilitated acquisition of better coping skills. 
Thus, the continued PHP level treatment provided the clinically appropriate components of the treatment that were provided with clinically appropriate structure, intensity of services, and monitoring. The continued PHP treatment through discharge was therefore medically necessary including continued monitoring for the duration of the proposed treatment in order to achieve a safe transition to lower level treatment and transition to IOP level care. None of this therapeutic work could have been safely or effectively provided at a lower level of care in view of the multiple, complicating factors in this case for the time interval under review.
This answer is consistent with prevailing standards of professional practice and ASAM criteria and scientific literature and published practice guidelines referenced below, as well as the application of NY STATE OASAS LOCADTR 3.0 Criteria that is applicable to this NY State mandated case review.
In this case scenario, the patient's co-occurring psychiatric disorders, persistent post-acute withdrawal symptoms and intense cravings, and lack of awareness or limitations of insight together with the seriousness of the substance use disorders is illustrated by her continued use despite functional decline and engagement in high-risk behaviors potentially impacting general health (dangerous combinations of drugs and unprotected sex), and despite having access to treatment in the community. 
The presence of high-risk behaviors and trauma related symptoms complicate this case. Additionally, the patient's co-occurring mental health issues that included mood disturbance and trauma symptoms were triggering the patient's use of substances including prominent and persistent symptoms. The patient recovery environment was not sufficient for treatment with lower level services during the time frame under review considering these clinical factors and treatment dimensions, and the patient did not have sober supports to sustain a recovery effort until she had worked with her family and committed to a recovery process.