Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use. 
Treatment: Inpatient substance abuse residential rehabilitative services.

The insurer denied coverage for inpatient substance abuse residential rehabilitative services.  The denial is overturned. 

This is a male patient who was admitted to inpatient substance residential treatment due to alcohol rehabilitation and initially also detoxification from alcohol. He reportedly had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 4 and then 7 and had tremors, sweats, anxiety, and headache and was prescribed Ativan for withdrawal. He had no reports of withdrawal seizures or complicated withdrawal. He reportedly was drinking 20 ounces of vodka per day and had past blackouts. He reported that alcohol interfered with his relationships and ability to work. He reportedly stated that life was out of control, unmanageable, and that he was unable to stop using alcohol on his own. He reportedly had comorbid anxiety and depressive symptoms including diagnoses of Generalized Anxiety Disorder and Major Depressive Disorder and was treated with Zoloft. He reportedly lived by himself. He reportedly lacked coping skills and was self-medicating his anxiety and depression with alcohol. He reportedly had no past substance/alcohol treatment.

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. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol daily despite negative consequences, including it interfering with relationships and ability to work. He reportedly lacked coping skills to maintain abstinence, needed to better identify relapse triggers, needed motivation for change, needed sober supports, better decision making and impulse control, and needed to develop relapse prevention skills. He was unable to stop 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 and had more negative consequences due to use.  

According to the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide, 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. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for inpatient substance abuse residential rehabilitative services is overturned. Medical necessity is substantiated.