Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for (1) all or any of the intensive outpatient program (IOP) level of care services. Findings:  The physician reviewer found that this patient met Level 2.1 criteria for IOP 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. Of note, according to the adolescent ASAM criteria, admission to a Level 2.1 program is indicated for a patient who meets the stability specifications in Dimension 1 and Dimension 2, and the severity specifications in at least one of Dimensions 3, 4, 5 and 6.For dimension 1, withdrawal symptoms are not required for Level 2.1 treatment. He met the stability specifications for a Level 2.1 treatment setting. For dimension 2, the patients biomedical conditions and problems, if any, were stable. The patient met the stability specifications.For dimension 3, the patient had a diagnosis of persistent depressive disorder, and the records noted that he was using cannabis to cope with his depression and anxiety. The patient had ongoing symptoms of dysthymia, including worthlessness and low energy/motivation. The patients recovery efforts were negatively affected by an emotional, behavioral, or cognitive problem.For dimension 4, the patient participated in treatment sessions but was noted as briefly relapsing on cannabis. The records noted difficulty with drug-seeking behaviors. The patient tended to have regression in behaviors on the weekends when he was not attending program, as evidenced by staying in bed all day. The patient required structured therapy and a programmatic milieu to promote progress through the stages of change as evidenced by behaviors being verbally compliant but not demonstrating consistent behaviors.For dimension 5, the patient continued to exhibit depressed affect and had difficulty with continued urges to use substances. There was a high likelihood that the patient would continue to use or relapse to use alcohol and other drugs without close outpatient monitoring and structured therapeutic services, as indicated by his lack of awareness of relapse triggers, difficulty in coping or postponing immediate gratification, or ambivalence toward treatment. For dimension 6, the patient lived at home with his family. The patient continued to struggle with social isolation. The patient lacked social contacts, had unsupportive social contacts that jeopardized recovery, and had few friends or peers who did not use alcohol or other drugs. He lacked the skills necessary to maintain an adequate level of functioning without Level 2.1 services.Given these findings, the patient met the six ASAM dimensions for IOP services. In this patients case, IOP level of care was in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, IOP level of care services were medically necessary for the 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 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.