Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee requested reimbursement for Intensive Outpatient Program (IOP) services. The patients stated diagnoses included attention deficit hyperactivity disorder (ADHD), panic attacks, learning disorders with impairment in reading and mathematics, and reactive attachment disorder. The patients listed medications included guanfacine and sertraline. The submitted documentation reflects that the patient was diagnosed with ADHD at eight noted as stalking a classmate at 10, and reported to have stolen property at 13. Records also indicate that the patient was having sexualized behaviors at 17 and that she was suspended from school for overly sexual behavior. The patients prior treatment included individual and family therapy as well as a wilderness program. She was admitted to a residential program. Records indicate that the patient had a long history of difficulty sustaining friendships and relationships, and that she was easily angered and aggressive if her perceived needs were not met. Records indicate that the patient had an extensive history of impulsive risky behaviors, which included stealing and unprotected sex with multiple partners. The submitted documents reflect that the patient was discharged from an IOP level of services to a young adult transition program. While the American Psychiatric Association (APA) guidelines do not mention IOP services specifically, they note that  indications for partial hospitalization (a level of care that is higher than IOP) include dangerous, impulsive behavior that is unable to be managed with outpatient treatment, a deteriorating clinical picture, complex comorbidity that requires a more intensive clinical assessment of the patients response to treatment, and symptoms of sufficient severity to interfere with functioning school or family life that are unresponsive to outpatient treatment. In this case, the records reflect that the patient had a history of engaging in dangerous, impulsive behaviors that were not managed with outpatient treatment. The patient had a deteriorating clinical picture, and her circumstances required an intensive clinical assessment of her response to treatment. In addition, her symptoms were sufficiently severe to have interfered with her school and family life while being unresponsive to outpatient treatment. Therefore, since the patient would have met APA guidelines for a higher level of care, such as partial hospitalization, she would qualify for a similar but lower level of care such as IOP. Under these circumstances, IOP was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patient's illness. Accordingly, the Intensive Outpatient Program (IOP) services were medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturnedCredentials/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.