Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol dependence, Nicotine dependence, Cannabis dependence

Treatment: Inpatient hospital stay

The insurer denied coverage for the inpatient hospital stay.

The denial is overturned. 

This is a male patient with a history of alcohol dependence, nicotine dependence, cannabis dependence and hypertension who was admitted for inpatient substance rehabilitation treatment due to alcohol, crack/cocaine, and cannabis addiction. The patient reportedly wanted to stop substance use and work on relapse prevention skills. The patient had multiple past inpatient substance detoxification treatments as well as a 14-day inpatient substance rehabilitation treatment.  

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 reported that it was difficult for him to stop his alcohol, cannabis, and crack/cocaine addiction, and the patient was asking for help in this 24-hour therapeutic substance rehabilitation treatment setting. A few months prior to this admission, the patient reportedly had a 14-day inpatient substance rehabilitation treatment and still was unable to maintain abstinence so he required even more time than the 14 days at this inpatient substance rehabilitation treatment level of care at this admission.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met the criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol, cannabis, and crack/cocaine despite multiple past inpatient substance detoxification. The patient was unable to comply with treatment outside of a 24-hour structured treatment setting. The patient also wanted to work on housing issues and possible employment, and he needed to work on having more sober supports, improve coping skills, work on relapse prevention skills, better identification of triggers, and improve his insight into his addiction. It was reported that after his first week, the patient was looking for long-term treatment after this. It was reported that after the second week, the patient had a drug dream and agreed to the Vivitrol shot to try to curb his cravings. It was reported that after the third week, the patient had a couple of drug dreams, and was trying to work on improving his social supports. It was reported that after the fourth week, the patient was prepared to undertake more long-term treatment.  

The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide, reports that research indicates 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 did not learn enough in two weeks of past inpatient substance rehabilitation treatment to maintain abstinence so he required the entire stay in this inpatient substance rehabilitation treatment. Without this structured and supervised therapeutic inpatient rehabilitation treatment setting, the patient likely would have relapsed again quickly.  

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

The carrier's denial of coverage for the inpatient hospital stay should be overturned. The medical necessity is substantiated.