Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  In general, the determination of the appropriate level of care for patients with addictive disorders complicated by depression and bereavement is a challenging endeavor.  The American Society of Addiction Medicine recommends placement based on a complex, individual assessment: Therefore, in clinical practice, the placement decision is the last step in a multidimensional assessment that guides the variety and intensity of services needed in an individualized treatment plan. Where the patient is placed should ideally be determined by the patient's unique treatment plan, not by reimbursement limitations, program ideology, or utilization reviewers. 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 particular case, the patient had a serious addiction to alcohol which contributed to interpersonal discord, depression and dangerous behaviors such as operating a motor vehicle while intoxicated.  He reported a family history and an early age of first use, both of which are associated with more severe cases of alcoholism.  He had a co-occurring psychiatric disorder.  He had strained relationships due to his drinking. Thus, the IOP placement was medically indicated.  According to the documentation, the patient demonstrated a harsh super-ego in his struggles with self-forgiveness, guilt and shame. The patient had not consolidated the treatment gains necessary to succeed in the outpatient setting. He had not yet developed a full appreciation of his disease and remained in denial.  The patient had yet to establish a sober network in the community.  He was not attending Alcoholics Anonymous regularly and did not have a sponsor.  He feared relapse. The patient was attending, participating and benefitting from the IOP services at a frequency of three times per week.  Thus, continued treatment remained reasonably expected to further the patients improvement while minimizing the chance of relapse, which in turn would have more than likely placed the patient and others at risk, and required a more intensive treatment setting. It is more than likely that in the absence of sustained sobriety, this patients chronic medical comorbidities would demand greater clinical attention. 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 and prevent a worsening of his medical condition. 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. Therefore, IOP services provided were medically necessary for treatment of this patient, but not thereafterFinal Result: The reviewer determined that the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.