Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services. Findings:  The physician reviewer found that this patient met Level 2.5 criteria for PHP services provided from 4/16/21 through 5/4/21. 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 ASAM criteria, transfer to a level 2.5 program from a higher level of care is indicated for patients that have met essential treatment objectives at a more intensive level of care and that require the intensity of services provided at Level 2.5 in at least one dimension.For dimension 1, the patient underwent withdrawal management for opioid withdrawal and had suboxone dosage adjusted throughout his treatment stay. The patients withdrawal needs can be safely managed in a Level 2.5 setting. For dimension 2, the patient has history of drug-induced seizures and chronic pain from numerous sports injuries. This patient reports that pain is a significant trigger for him as he was initially started on oxycodone to manage his pain. The patients biomedical conditions and problems are not sufficient to interfere with treatment but are severe enough to distract from recovery efforts. The patient qualified for PHP services based on meeting these criteria. For dimension 3, the patient has been diagnosed with anxiety disorder and depression. It was noted by the treatment team that the patient uses opioids to cope with depression. Problems in dimension 3 are not necessary for admission to a Level 2.5 program. For dimension 4, the patient struggled with consistent participation in the treatment milieu and he frequently left groups before dismissal. The patient misused his suboxone and was discharged from the program. The patients perspective and lack of impulse control inhibited his ability to make behavioral changes without repeated, structured, clinically directed motivational interventions. Such interventions were not feasible or not likely to succeed in a Level 2.1 program. However, the patients willingness to participate in treatment and to explore his level of awareness and readiness to change suggest that treatment at Level 2.5 can be effective. The patient qualified for PHP based on meeting this criteria. For dimension 5, the patient was continued on suboxone but continued to have ongoing cravings and anxiety. The patient reportedly misused his suboxone and he was discharged from the program. The records document that there was a high likelihood that the patient would continue to use or relapse to use of substances 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. He qualified for PHP based on meeting this criteria. For dimension 6, the patient is now living in a sober living facility. The patient required the intermittent structure of Level 2.5 treatment services and relief from the home environment in order to remain focused on recovery. According to the ASAM criteria, PHP placement is indicated for patients meeting criteria in at least one of the dimensions. This patient meets criteria in dimensions 2, 4, and 5 and ASAM does not require that he meet criteria in the remaining dimensions. Moreover, the PHP services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. Therefore, the PHP 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 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.