Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Substance Abuse Rehabilitation

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

This is a male patient with a past history of inpatient substance/alcohol detoxification and rehabilitation treatments. He reported drinking 12 to 1 pint of alcohol several times per week and inhaling multiple bags of heroin per day.  He presented for inpatient substance rehabilitation treatment after completing several days of inpatient substance detoxification treatment. He was seeking further rehabilitation to help him identify relapse triggers and to gain coping skills to sustain abstinence. 
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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 was using large amounts of alcohol and heroin which put him at high risk for overdose, and he reportedly could not stop use on his own without a structured 24 hour therapeutic supervised and structured inpatient rehabilitation treatment setting. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of heroin and alcohol and was considered a high risk patient with lack of supports who reportedly was homeless.  He also reportedly lacked coping skills to maintain abstinence, needed to better identify relapse triggers, needed sober supports, better decision making and impulse control, and he needed to develop relapse prevention skills.  He reportedly continued to use large amounts of heroin daily and alcohol several times per week despite past inpatient substance/alcohol detoxification and rehabilitation treatments.  He was unable to stop substance and alcohol use without being in a sober and supervised therapeutic inpatient substance residential setting then.  Without this structured and supervised therapeutic inpatient substance rehabilitation treatment he likely would have relapsed quickly.  

The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide reports 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 treatment techniques to increase motivation for treatment are necessary to prevent dropout rates.  In this case this patient required this 24 hour rehabilitation treatment as he was at high risk to continue use of alcohol and heroin without this 24 hour therapeutic substance rehabilitation treatment setting and needed to develop the necessary skills for abstinence.  He continued to be at high risk for relapse and required the structured and supervised therapeutic rehabilitation setting then. 

It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the individual then.  

The carrier's denial of coverage for the inpatient substance abuse rehabilitation admission is reversed.  The medical necessity is substantiated.