Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.1 criteria for PHP services and prospective RTC 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 has no signs or symptoms of withdrawal. Thus, she can safely be managed in in a Level 3.1 setting. For dimension 2, the patient was found to have a current biomedical condition of gastroparesis, which causes her to feel bloated and full, and further perpetuates her cognitive distortions about her weight. Although the patients gastroparesis is not severe enough to require inpatient treatment, it is sufficient to distract from her treatment and recovery efforts. This problem requires medical monitoring, which can be provided by the program. In addition, the patient has continued to reduce her caloric intake due to gastrointestinal distress. At a lower level of care, she started to abuse drugs and alcohol, which aligned with her eating disordered behaviors. The provider noted that the patient has increased to daily binge and purge behaviors triggered by her medical condition and she has required extensive nutritional monitoring and supervision during meals. For dimension 3, the patients mental status is sufficiently stable to allow her to participate in the therapeutic interventions provided at this level of care and to benefit from treatment. The patients significant anxiety related to her co-occurring PTSD places her at imminent risk of relapse with dangerous consequences to include worsening gastrointestinal complications outside of a structured environment. The providers has continuously documented that the patients impulsivity and other negative emotions are so significant that they cannot be managed outside of the structure and support provided at this level of care. Moreover, the patients borderline personality disorder became so severe and progressive toward the end of her IOP stay that she was discharged to a higher level of care and co-occurring and enhanced program that also specialized in treatment of borderline personality disorder. The complexity of treatment, in this patient with borderline personality disorder, PTSD, and an eating disorder requires an intensive multidisciplinary team approach. The patient has a diagnosed behavioral disorder that requires assessment of psychiatric symptoms because the patients history suggests that these disorders are likely to distract her from treatment efforts. For dimension 4, the patient requires a 24-hour structured milieu to promote treatment progress and recovery, because motivational interventions have failed in the past at a lower level of care. The patients symptoms progressively worsened while in IOP, which required step up to a higher level of care. The patient is at high risk of substance use, deteriorated mental functioning, and dangerous emotional and behavioral consequences in the absence of a 24-hour structure to help her apply her coping and recovery skills. The provider noted that the patient will not be able to meet her minimum needs and will not have the emotional support without adequate supervision at a lower level of care. The patients discharge summary summarized her decline with decreased supervision at a lower level of care. The provider noted that the patient has been restricting her intake to fewer than 700 kcals per day with gastrointestinal distress and purging behaviors that increased to daily bingeing and purging. For dimension 5, the patient has demonstrated limited coping skills to address relapse triggers and urges and deteriorating mental functioning. The patient is in imminent danger of relapse, with dangerous behavioral consequences, and needs 24-hour structure to help her apply recovery and coping skills. The patients status in this dimension is characterized by psychiatric symptoms including impulsivity, mood lability, guilt, and an unrealistic body image that pose a moderate risk of relapse to her substance use disorder and mental disorder. Thus, 24-hour structure at a Level 3.1 co-occurring enhanced program is appropriate to maintain an adequate level of functioning. The provider noted that when the patient demonstrated deterioration of functioning, her mood disorder creates an obstacle to accessing the eating disorder. For dimension 6, the patient has been able to cope, for limited periods of time, outside the 24-hour structure of a 3.1 Level program in order to pursue community activities. The patients living environment is characterized by a moderately high risk of substance use endemic that the patient is assessed as being unable to achieve or maintain recovery in a less intensive level of care. The patients living environment places her at risk of resuming substances and engaging in her eating disordered behaviors. Given these findings, the patient meets the six ASAM dimensions for PHP level of care and for admission to a RTC facility. Thus, the PHP level of care services and prospective RTC level of care services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are 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 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.