Appeal type: Medical necessity
Decision: Overturned

Diagnosis: substance abuse.

Treatment is substance use, inpatient rehabilitation treatment.

The insurer denied coverage for substance use, inpatient rehabilitation treatment.
 
The denial is overturned.

This male patient reportedly was admitted to this inpatient substance rehabilitation treatment. He had multiple past inpatient treatment episodes including past inpatient substance detoxification treatment and rehabilitation treatments. He reportedly could not maintain abstinence despite these treatments. He reportedly lived with his girlfriend. He had bipolar disorder and had past psychiatric hospitalizations for that. He was spending his retirement funds to support his use. He reportedly took Clonidine and Benadryl, attended group and individual therapy. He completed this program and was discharged.
  
The denial for the coverage for inpatient substance rehabilitation treatment is overturned as the medical records provided enough specific evidence to support that he required this level of care. The APA (American Psychiatric Association) 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 and using serious substances including cocaine which put him at risk medically and also for severe, complicated, and life-threatening withdrawals. He lacked the coping skills and ability to identify relapse triggers to stop use. He also had a comorbid psychiatric diagnosis of bipolar disorder-and had past psychiatric hospitalizations. He lacked positive peer support, lacked coping skills for abstinence, and lacked the ability to identify triggers to use or insight into use. Notes reported that he said he couldn't be managed in an outpatient setting as he continued to use and also use his retirement funds to support his use. Notes reported that he was working on how his emotions contributed to his use. Notes reported that he needed to learn better coping skills, improve insight into use, better identify relapse triggers, and to learn how to better deal with drug cravings. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. 

The National 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 the entire time in this therapeutic, structured and supervised inpatient rehabilitation treatment. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly as evidenced by relapsing after multiple past inpatient substance/alcohol treatments.  

The insurer's denial of coverage for substance use, inpatient rehabilitation treatment is overturned. Medical necessity is substantiated.