Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.

Treatment: Substance Abuse Inpatient Rehabilitation Services.

The insurer denied coverage for Substance Abuse Inpatient Rehabilitation Services.

The denial is overturned.

This patient reportedly was admitted to this inpatient substance rehabilitation treatment. The patient reportedly was drinking 12 pint of tequila daily with a 23-year history, using 2 grams of intranasal cocaine with a 3-year history, and was smoking 14 ounce of tetrahydrocannabinol (THC) daily with a 23-year history. The patient reportedly had a positive toxicology for cocaine, THC, and benzodiazepines. The patient reportedly lived alone and lacked coping skills to maintain abstinence or better identify relapse triggers. The patient reportedly had a recent inpatient detoxification treatment and had past outpatient substance treatment and relapsed and could not maintain abstinence. The patient reportedly left against medical advice (AMA).

The insurer denied coverage for inpatient substance rehabilitation treatment as not medically necessary treatment then. They stated that the patient did not require 24-hour inpatient treatment, could participate in treatment outside of the 24-hour setting, had no co-occurring medical or psychiatric conditions requiring inpatient care. They also stated that the patient had no complicated withdrawal or life-threatening medical conditions. They recommended a less restrictive level of care then.

The 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 then. The American Psychological 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 the patient reportedly was using large amounts of alcohol, cocaine, and cannabis daily and could not stop use despite past inpatient substance detoxification and rehabilitation treatment. The patient reportedly lacked the coping skills and ability to identify relapse triggers to stop use and reportedly could not maintain any abstinence. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as the patient continued to use large amounts of substances daily putting them at risk medically and for severe withdrawal despite past inpatient rehabilitation and detoxification treatment. Without this structured and supervised therapeutic rehabilitation treatment the patient likely would have relapsed quickly, as evidenced by relapses after other inpatient substance treatment settings as well as recent past outpatient substance treatment just prior to this admission. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance rehabilitation treatment. 

Based on the above, the insurer's denial must be reversed. 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 services is substantiated.