Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Substance Abuse Treatment. 

The insurer denied coverage for substance abuse treatment. 

The denial is overturned. 

This patient was admitted to a substance residential treatment as a self-referral due to crack/cocaine and marijuana use. He reportedly had increased frequency of use and this reportedly was his 6th substance treatment. He was not allowed to live with his wife while using so he was considered homeless. He reportedly spent 100 days in the county jail prior to admission. He also had comorbid psychiatric issues including anxiety and depression and had trauma issues including childhood trauma. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but 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. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. In this case this patient was considered still in need of 24 hour residential treatment then as he needed time in this 24 hour inpatient therapeutic structured and supervised setting to learn better coping skills, relapse prevention skills, improve insight into his addiction including how his psychiatric comorbidities contributed to his addiction, better identify relapse triggers, improve motivation, and increase sober supports. 

The Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that research indicates that that the best treatment outcomes occur with longer durations of treatment and states that recovery from drug addiction is a long-term process. It also states that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. In this case this patient required more treatment time in a 24-hour inpatient therapeutic residential treatment setting including. Notes reported that he was making progress and would benefit from further inpatient substance residential treatment, and that he needed to work on aftercare goals and barriers to obtaining them. Notes reported that he was still working on trying to better understand how his emotions and thoughts triggered his use. Notes reported that cognitive behavioral therapy (CBT) was used to try to connect thoughts and feelings with his behaviors and use and that he still had housing issues and was considered at risk for another relapse due to past relapses after 5 other substance treatments, so he required more time in this setting. It was reported that he was making progress and would benefit from further inpatient substance residential treatment. Notes reported that he still had insomnia despite taking Melatonin and he also took Sertraline for anxiety and depression.  This was a complex patient who could not stop crack/cocaine or marijuana use despite 5 other substance treatments and needed at least the entire time in this sober therapeutic 24-hour residential rehabilitation treatment to develop relapse prevention skills, strengthen coping skills, decrease impulsivity, better identify triggers, improve insight into how his comorbid psychiatric and trauma issues contributed to his use and addiction, and increase sober supports. He had multiple relapses despite past substance treatments and required this level of care including during the denial period and needed to learn how to make better decisions and not self-medicate his psychiatric and trauma issues. At the time of the denial, he still had not obtained the skills needed to remain sober and was still working on them. Due to his difficulties with expressing emotions in a healthy manner, if he were discharged prematurely, he was considered a high risk for relapse.  Without this structured and supervised therapeutic residential treatment, he likely would have relapsed quickly. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the substance abuse treatment is overturned. Medical necessity is substantiated.