Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for partial hospitalization program (PHP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 2.5 criteria for PHP 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 signs or symptoms of withdrawal. For dimension 2, the patient has no reported medical problems. The patients biomedical problems, if any, were not sufficient to interfere with treatment. For dimension 3, the patient experienced difficulties with depression. He has diagnoses of substance-induced psychosis and schizoaffective disorder. He has required at least six prior inpatient psychiatric hospitalizations for cannabis-induced psychosis. He was readmitted to the inpatient service within seven days of discharge due to relapse on cannabis and resultant psychosis. The patient was at mild to moderate risk of behaviors endangering self, others, or property, and was at imminent risk of relapse, with dangerous emotional, behavioral, or cognitive consequences, in the absence of Level 2.5 structured services. For dimension 4, the patient voluntarily admitted himself to the PHP after an inpatient psychiatric admission for psychosis within a week of discharge from the hospital. He continued to express doubts that he had a problem with his cannabis usage. 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 were not likely to succeed in a Level 1 or a Level 2.1 program. However, the patients willingness to participate in treatment and to explore his level of awareness and readiness to change suggested that treatment at Level 2.5 could have been effective. For dimension 5, the patient relapsed on marijuana twice in the past month. He had an inability to identify coping skills and tools to prevent relapse. He also expressed ambivalence regarding his marijuana usage and if it was problematic. There was high likelihood that the patient would continue to use or relapse 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. For dimension 6, the patient was unemployed and living with his mother. The provider noted that the patients relationship with his mother was strained and he had an otherwise limited social network with little structure. The patient identified his relationship with his mother as one of his triggers for relapse. Continued exposure to the patients current living environment would have 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 PHP services. Therefore, the PHP services were medically necessary for treatment of this patient. 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.