Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: substance use - inpatient rehabilitation treatment, 20 days

The insurer denied coverage for substance use - inpatient rehabilitation treatment, 20 days

The denial is overturned

This patient was admitted to this inpatient substance rehabilitation treatment for alcohol and crack/cocaine rehabilitation treatment. He reportedly was drinking 2 pints of alcohol per day and smoking $200 worth of crack/cocaine per day and was spending all his money to support his use. He had diagnoses of Cocaine Use Disorder and Alcohol Use Disorder. He reportedly had multiple past treatment episodes with relapse and could not maintain abstinence with recent inpatient substance rehabilitation one (1) month prior to this admission, and an inpatient substance detoxification treatment three (3) months prior to this admission. He had comorbid mental health issues including a diagnosis of bipolar disorder and took Wellbutrin and Abilify. He reportedly attended group and individual therapy. He reportedly was discharged with follow up for long term substance/alcohol residential treatment.
    
This reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment as the medical records provided enough specific evidence to support that he required this level of care. 

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 up to 2 pints per day and using serious substances including crack/cocaine up to $200 worth per day which put him at risk medically and at risk for severe, complicated, and life-threatening withdrawals. He lacked the coping skills and ability to identify relapse triggers to stop use. He reportedly had comorbid psychiatric issues including bipolar disorder diagnosis and mood symptoms which triggered use. 

According to the Level of Care for Alcohol and Drug Treatment Referral 3.0 (LOCADTR3) he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol daily and also used crack/cocaine daily, despite multiple past inpatient substance detoxification and rehabilitation treatment, and inability to maintain abstinence. He reportedly had an unstable recovery environment, lacked coping skills and ability to identify relapse triggers.  The goal was for him 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 also considered at risk medically due to his large amount of alcohol and crack/cocaine use and required inpatient rehabilitation treatment.  He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. 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.  Furthermore, he was discharged to a long-term inpatient substance residential treatment for further inpatient substance/alcohol 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 use - inpatient rehabilitation treatment, 20 days is substantiated.