Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Substance Rehabilitation Treatment

The insurer denied the Inpatient Substance Rehabilitation Treatment. The denial was reversed.   

This is a male patient with a history of hypertension. He presented to a treatment facility for inpatient substance residential treatment. It was reported that had relapsed and was mandated back into a program. He reported using several bags of heroin every other day. He had a positive toxicology for opiates. While in treatment he attended group therapy reporting that he was still having struggles with urges and was working on improving his coping skills.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24 hour substance rehabilitation treatment as he continued to use substances despite negative consequences to use, and he reportedly was still struggling with thoughts and urges to use, needed more time to work on coping skills and relapse prevention skills in order to try to maintain abstinence. He reportedly relapsed after past treatment and required more time in this treatment setting to learn more skills to give him the best chance of abstinence. 

According to the LOCADTR he met criteria for inpatient substance residential rehabilitation treatment as he continued to use substances including heroin despite past inpatient substance treatments including recent inpatient substance treatments. Also, despite negative consequences of substance use, he could not stop using substances without the 24 hour therapeutic supervised and structured programming of this therapeutic residential treatment setting. It was reported that he had minimal engagement and his attitude did not show that he was making the changes needed, and he required more work on relapse prevention skills and self-esteem. He needed to show more engagement and commitment to accomplishing goals. 

The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that research indicates that most addicted individuals needs at least several months in treatment to significantly reduce or stop their drug use and that the best treatment outcomes occur with longer durations of treatment. It also states that recovery from drug addiction is a long term process and that a treatment technique to increase motivation for treatment is necessary to prevent dropout rates. He reportedly had urges and relapsed recently even with past treatment. He was at risk for overdose due to use as well so he needed to have more time in this setting to give him the best chance of abstinence. Without this structured and supervised therapeutic residential treatment, he likely would relapse sooner and be more at risk for relapse and overdose so he needed a significant amount of time in this treatment setting to give him the best chance of abstinence. 

It did not appear that the health care plan acted reasonably or in the best interests of the individual.

Based on the above, the medical necessity for inpatient behavioral health services is substantiated.  The insurer's denial is reversed.