Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for intensive outpatient program (IOP). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  The medical literature supports a 90-day course of IOP services as medically necessary in this this clinical setting.  Additionally, the practice guideline jointly authored by the Department of Veterans Affairs and Department of Defense supports more intensive settings for certain cases:  There is now a fair amount of research that indicates patients with greater substance use severity and co-occurring problems such as psychiatric disorders and housing problems will do better in more intensive forms of treatment.  In this case, the patients substance use disorders were complicated by co-occurring depression and anxiety.  This is of particular relevance since it has been well-established that anxiety-ridden mood disorders, without the complication of addictive illness, are notoriously difficult to treat and in general have poorer outcomes.  Although the patient showed signs of steady improvement, she had not consolidated the treatment gains necessary to succeed with an appointment once a week prior to being admitted.  Instead, she had significant psychiatric and medical co-morbidity.  She was anxious.  She was having urges to drink and slowly tapering lorazepam, while changing pro-serotonergic medication from sertraline to escitalopram.  She was also prescribed an anti-drinking medication, disulfiram.  However, the patient was attending, participating and benefitting from the IOP services at a frequency of three times per week.  She received a full range of therapies including dialectical behavioral therapy to better regulate her emotions.  During her IOP care, the patient wrote a break up letter to alcohol and she proclaimed her desire for sustained sobriety.  A day later her anxiety was much improved while her motivation for recovery remained a 10 out of 10.  The following week she had no depression and had improved on six of seven objective domains, all of which indicate that the treatment was helpful to the patient.  In sum, considering the relevant peer-reviewed literature, current practice guidelines and the case in its entirety, service delivery at the IOP level of care was safe, appropriate and consistent with good medical practice. A 90-day treatment course aligns with community standards for a case of this complexity and would be reasonably expected to improve the patients condition, bolster relapse prevention efforts and prevent a more serious episode of illness. Therefore, IOP services were medically necessary for 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.