Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder
Treatment: Inpatient rehabilitation admission
The insurer is denied coverage for inpatient rehabilitation admission
The denial is reversed. 

This patient was a male who was admitted to inpatient substance rehabilitation treatment after completion of inpatient substance detoxification treatment. The patient had a long history of alcohol use and was drinking large amounts of alcohol including 1 pint of vodka and a few 16 ounce beers daily. The patient's urine toxicology was positive for benzodiazepines. The patient's medical issues included atrial fibrillation and hypertension. The patient had multiple past inpatient detoxification and rehabilitation treatments and still relapsed. The patient attended individual and group therapy and was discharged
.
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 reportedly was using large amounts of alcohol daily including 1 pint of vodka and a few 16 ounces of beer daily. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met the clinical criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol daily and had a positive benzodiazepine toxicology screen despite multiple past inpatient substance detoxification and rehabilitation treatments. The patient reportedly lacked coping skills and the ability to identify relapse triggers to stop use. The patient reportedly lacked insight and judgment. The patient was also noted to have a sad mood and anxiety. The patient was unable to stop alcohol use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting then, and he was admitted after completing an inpatient substance detoxification treatment. 

Notes reported that the patient was keeping to himself. Notes reported that the patient was working on improving coping skills and working on sobriety and relapse prevention. Notes reported that the patient was motivated for treatment, working on coping with stressors. Notes reported that the patient was working on stress management, assertiveness and communication. Notes reported that the patient was encouraged to verbalize better. Notes reported that the patient was verbalizing more in individual therapy and was more engaged in group therapy and was receptive to working on coping skills and recovery skills, as well as decision making. Notes reported that the patient was working on coping mechanisms. The patient was discharged.  

Without this structured and supervised therapeutic rehabilitation treatment, the patient was likely to have relapsed quickly as evidenced by this patient's pattern of relapses after multiple past inpatient detoxification and rehabilitation treatments. Based on literature review, inpatient rehabilitation admission was medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient rehabilitation admission is substantiated.  The insurer's denial should be reversed.