Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for substance abuse intensive outpatient program (IOP) treatment. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 2.5 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 documented signs or symptoms of withdrawal. For dimension 2, the patients biomedical conditions and problems were stable and not sufficient to interfere with treatment but were severe enough to distract from recovery efforts. The patient has HIV and is on Biktarvy. For dimension 3, the patient had difficulties with depression and anxiety and was treated with fluoxetine. Problems in dimension 3 are not necessary for admission to a Level 2.5 program. For dimension 4, the patient admitted himself voluntarily to the IOP program after a weekend binge. He has been using cocaine in a binge type fashion for the past 10 years and drinking one-half bottle of wine daily for the past two years. He has experienced loss of his long-term relationship and was using substances to cope with the anxiety. As evidenced by his urinalysis that was positive for amphetamines and a relapse on cocaine after a car accident, the patient appears to have impulse control difficulties. The patients perspective and lack of impulse control inhibits his ability to make behavioral changes without repeated, structured, clinically directed motivational interventions. Such interventions are not feasible or likely to succeed at a Level 1 or 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 could be effective. For dimension 5, the patient relapsed twice during his IOP treatment, on amphetamines and on cocaine due to the stress of a car accident. He appears to have difficulty in coping or postponing immediate gratification. There was high likelihood that the patient would have continued 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. The patient has unsuccessfully attempted treatment at a less intensive level of care, or such treatment is adjudged insufficient to stabilize the patients condition so that direct admission to Level 2.5 is indicated. For dimension 6, the patient was living alone but his ex-partner, who actively uses substances, visited on a routine basis. He was having difficulty with work due to the COVID-19 pandemic. He had little structure and few friends. Continued exposure to the patients current living environment rendered recovery unlikely as the patient lacked the resources or skills necessary to maintain an adequate level of functioning without the services of a Level 2.5 program. Given these findings, the patient met the six ASAM dimensions for substance abuse IOP services. Therefore, the substance abuse IOP treatment was 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.