Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Partial Hospitalization Substance Use Treatment 
The insurer denied the Partial Hospitalization Substance Use Treatment.
The denial is upheld. 

The patient is a male. He presented for partial hospital program (PHP) level substance use disorder rehabilitation treatment to address substance use of alcohol. The patient had no past history of delirium tremens or withdrawal seizures, but had chronic medical conditions including hypertension, gout and GERD (gastroesophageal reflux disease) with associated treatments. He had a history of substance use disorder with onset in adolescence, escalating to daily continuous use of approximately 12 to 18 beers per day. The patient self-referral for treatment was prompted by a family intervention and the admission for PHP (partial hospitalization program) level care had immediately followed a seven-day detoxification treatment. The patient had not previously engaged in substance use disorder treatment. 

There was a history of psychiatric disorder diagnosed as an unspecified anxiety disorder and major depressive disorder. The patient denied history of psychiatric hospitalization or suicidal or self-harming behavior. He indicated that he had trauma history with physical abuse at the hands of his in-laws.

The patient was motivated for rehabilitation treatment. The patient exhibited fair, but limited insight and fair judgment and control of impulses. There were no severe symptoms on mental status examination; the patient had no symptoms of mania, psychosis, perception, cognition, or thought disorder. The patient was described as "neat" and "cooperative" with good eye contact. He was depressed with sad affect and exhibited anxiety and complained of insomnia. He presented with post-acute withdrawal symptoms including sweats, tremor, chills and fatigue, as well as the depression, anxiety and insomnia. 

The patient was married with children, and he lived with his spouse who was sober. He was employed. He had trauma/abuse history as noted, and there were no legal issues in this case.

The patient's rehabilitation treatment included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with 12-step recovery groups. The patient engaged in treatment and intensive services, sober housing, monitoring, and structure provided within the rehabilitation treatment program. The patient participated actively with treatment, and showed no severe symptoms or signs of withdrawal, and had no complications of rehabilitation treatment during his brief PHP (partial hospitalization program) stay earlier in the year. The patient participated in activity therapies and other therapeutic interventions to improve insight and life skills. He received vitamins and supplements, and medications that included Lexapro, Buspar, trazodone and prn (as needed) Vistaril. His blood pressure was normal during his brief stay and he was receiving medications including spironolactone and omeprazole. He was discharged from PHP (partial hospitalization program) level care with transfer/step down to intensive outpatient program (IOP) level care with sober living. Submitted documents that the patient continued substance use disorder rehabilitation treatment with discharge from the IOP (intensive outpatient program).

No, the Partial Hospitalization Substance Use Treatment was not medically necessary for this patient.

The substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was generally motivated and able to effectively engage in rehabilitation services. The patient's clinical features and treatment needs did not warrant the structure or monitoring or intensity of services of a PHP (partial hospitalization program) level of care in order to safely and effectively provide rehabilitation substance use disorder rehabilitation treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms in this case that would have required PHP (partial hospitalization program) level structure, monitoring or the intensity of inpatient level services. Moreover, the patient was not at risk for inpatient level care. The patient had support from family for the substance use disorder treatment with access to sober housing or supports, and the availability of peer support. Thus, the Partial Hospitalization Substance Use Treatment was not medically necessary for this patient.

This answer is consistent with prevailing standards of professional practice, published practice guidelines, ASAM (American Society of Addiction Medicine) Criteria, and the scientific literature, referenced below, as well as New York State instruction regarding medical necessity reviews and the application of NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria, referenced below.

The patient was generally motivated to actively engage in rehabilitation treatment without biomedical complications or significant withdrawal symptoms. He was able to engage and participate actively in the treatment plan without complication. There were no severe psychiatric disturbances or general medical concerns that required PHP (partial hospitalization program) level services, structure or monitoring, as noted in the answer to question 2. The patient was noted to benefit in all aspects of his treatment plan throughout his brief stay and had access to treatment at a lower level of care in a less restrictive treatment setting. Thus, the patient's substance use disorder rehabilitation treatment could have been effectively provided at a lower level of care including sober housing or supports, and other supportive services including peer support through 12-step recovery groups such as Alcoholics Anonymous (AA) and/or the consideration of medication assisted treatment. Moreover, the application of NY (New York) State OASAS (Office of Addiction Services and Supports) LOCADTR (level of care for alcohol and drug treatment referral) 3.0 Criteria/Guidelines does not support the PHP (partial hospitalization program) level treatment, as the health plan asserts.