Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for intensive outpatient program (IOP) services (ASAM Level 2.1). Based on the submitted documentation, this patient met ASAM Level 2.1 criteria for RTC. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. Of note, problems in dimensions 1, 2 and 3 are not necessary for admission to a level 2.1 program, so these criteria will not be reviewed. According to the ASAM criteria, IOP placement is indicated for patients meeting criteria in at least one of Dimensions 4, 5, or 6. With regard to dimension 4 (readiness to change), this patient was initially motivated for treatment and actively participated. This dimension was not met. In terms of dimension 5 (relapse, continued use, continued problem potential), this was the patients first attempt at outpatient substance abuse treatment after a 30-day residential treatment center stay. He has been clean from cannabis since before the residential treatment center stay, but admitted at times he used alcohol in an abusive manner to calm his anxiety and also mentioned that he misused his stimulant medication while in the IOP program. It was recommended that he stop the stimulants, but he was unwilling to do so. He admitted to struggling with coping with social situations without resorting to wanting to take a medication or have a drink. Thus, there was a high likelihood that the patient would have relapsed without close outpatient monitoring and structured therapeutic services, as indicated by his lack of awareness of relapse triggers, difficulty in coping, or ambivalence toward treatment. Thus, this dimension was met. With regard to dimension 6 (recovery environment), the patient was living at home with his parents. He was unemployed and was very isolative. His friend group reportedly used cannabis. Thus, the records indicate that the patient lacked social contacts, had unsupportive social contacts that jeopardized recovery, and few friends or peers who do not use alcohol or other drugs.  He also lacked the resources or skills necessary to maintain an adequate level of functioning without the services of a Level 2.1 program. Thus, this dimension was met. According to the ASAM criteria, IOP treatment is indicated for patients meeting criteria in at least one of dimensions 4, 5, or 6. This patient meets criteria in dimensions 5 and 6, and it is not necessary that he also meet criteria in Dimension 4. Therefore, IOP services (ASAM Level 2.1) 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 with sub-specialty certification in addiction 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.