Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polysubstance abuse

Treatment: Substance abuse - Inpatient rehabilitation, 14 days 

The insurer denied coverage for Substance abuse - Inpatient rehabilitation, 14 days

The denial is overturned.

This patient reportedly was admitted to this inpatient substance rehabilitation after completing an inpatient substance detoxification treatment. The patient reportedly was using 4-5 bags of heroin per day and 2 pills of Xanax per day. The patient reportedly started opioid use since age 12 and was taking Methadone since age 30. The patient reportedly was in a Medication Assisted Treatment (MAT) and was taking Methadone but still was relapsing by using heroin despite MAT. The patient reportedly had started using benzodiazepines since age 50. The patient reportedly had multiple past inpatient substance detoxification and rehabilitation treatments and relapsed and could not maintain abstinence. The patient reportedly was noncompliant with his psychotropic medications for bipolar disorder and anxiety and reported increased desires to use substances when not taking these psychotropic medications. The patient also reportedly had medical issues including diabetes and asthma. The patient reportedly had 2 past heroin overdoses. The patient reportedly lacked coping skills and support to maintain abstinence.
  
The insurer denied coverage for inpatient substance rehabilitation treatment as not medically necessary treatment then. They stated that the patient did not have medical or mental health concerns requiring 24-hour inpatient substance rehabilitation treatment then. They recommended a less restrictive level of care then such as outpatient substance abuse treatment.
   
The medical records provided in this case give enough specific evidence to support that the patient required at least this level of care at the time of admission. 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. The patient reportedly was using 4-5 bags of heroin per day and 2 pills of Xanax per which put them not only at risk for another overdose but also at risk for medical complications due to use and also at risk for severe withdrawal.  As such, the patient required inpatient substance rehabilitation treatment at that time. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as they continued to use large amounts of substances daily putting them at risk medically and for severe withdrawal despite multiple past substance treatment episodes including inpatient rehabilitation and detoxification treatments. The patient reportedly still was unable to maintain abstinence despite these past treatments including past inpatient rehabilitation treatment, so the patient required at least that level of care during this treatment episode. The medical records provided enough specific evidence to support that the patient required inpatient substance rehabilitation treatment. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for substance abuse - inpatient rehabilitation treatment, 14 days is substantiated.