Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet 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. For dimension 1, the patient had no signs or symptoms of withdrawal. He attended one day of ambulatory detoxification. There was no documented history of complicated withdrawal. For dimension 2, the patients biomedical conditions and problems were not sufficient to interfere with treatment and were not severe enough to distract from recovery efforts. Based on the clinical findings, the patient did not meet this requirement. For dimension 3, the patient was in outpatient therapy and received medication management from his primary care provider. His psychotropic medications on admission included Wellbutrin, Sonata, trazodone, and Xanax. There was no evidence of any acute psychiatric risk issues, such as thoughts of harming himself or others. His primary mental health issue during his admission was anxiety. The patients symptoms did not result in a high potential for distraction from treatment. Based on the clinical findings, the patient met the criterion of mild severity with potential to distract from recovery. For dimension 4, the patient voluntarily presented for treatment. He recognized increasing problems with alcohol since the onset of the COVID-19 virus pandemic. The records document a longer history of alcoholism with multiple legal consequences. The patient followed through with actively attending and participating in treatment. He had some barriers, based on his work schedule, to attending 12-step meetings and finding a sponsor, but he was motivated to participate. He also was started on medication-assisted treatment, naltrexone, during his stay. The patient did not meet the subcriteria of variability in engagement in treatment. For dimension 5, the patient maintained sobriety at the IOP level of care throughout his episode of treatment. He was started on medication-assisted treatment. The patient reported that there were several incidents during his IOP treatment that he was confronted with situations that would have prompted him to drink in the past, but he was able to utilize appropriate coping skills. The patient did not meet 2.1 criteria for this dimension, which requires severe intensity of addiction or mental health symptoms indicating a high likelihood of relapse or continued use. For dimension 6, the patient had a roommate who drinks, but was supportive of his recovery. He agreed to not drink around the patient or come home drunk. The patient planned to improve his communication with his mother. He received positive feedback from work. The patient did not meet the 2.1 requirement since his recovery environment was supportive. The ASAM criteria for adults requires all six dimensions to be met based on clinical history. In this case, the patient did not meet all six ASAM dimensions. Therefore, the IOP services were not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine 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.