Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Continued inpatient substance use rehabilitation treatment. 

The insurer denied coverage for continued inpatient substance use rehabilitation treatment. 

The denial is overturned. 

This male patient reportedly was admitted to inpatient substance rehabilitation treatment due to alcohol and substance rehabilitation. He reportedly had an inpatient detoxification treatment just prior to this inpatient rehabilitation treatment. He reportedly was drinking a 6 pack plus per day and smoking cannabis daily and had a history of use. He reportedly had early-stage liver disease due to alcohol use and elevated liver function tests (LFT's). He reportedly was noncompliant with his psychotropic medication when drinking alcohol and he had a recent psychiatric hospitalization due to a manic episode after noncompliance with medications. He reportedly had multiple past substance/alcohol treatment and continued to relapse and drink. He reportedly had alcohol related blackouts and alcohol related memory loss. He reportedly had aggression as he reportedly destroyed the house he was living in with his mother. 

This was when he was intoxicated with alcohol. This reportedly involved police. He reportedly had a diagnosis of schizoaffective disorder. He reportedly attended group and individual therapy to improve coping skills, better identify relapse triggers, improve sober supports, improve motivation as he had external motivation due to legal issues including a harassment charge. He reportedly applied for a step down to a long-term substance residential treatment but was not accepted until later and then he was discharged from this facility. 
  
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), he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol and cannabis daily and could not stop use outside of this 24-hour program. In this case this patient was considered in need of 24-hour substance rehabilitation treatment for the entire inpatient substance rehabilitation treatment stay as he could not stop alcohol and substance use despite negative consequences to use including legal problems, medical problems including liver disease, and noncompliance with psychotropic medications when drinking resulting in a recent psychiatric hospitalization due to a manic episode. He reportedly was aggressive physically and destroyed his home where he lived with his mother. He was considered a danger to self and others due to alcohol use and substance use and needed 24-hour inpatient rehabilitation treatment as he also was recently in an inpatient detoxification prior to this rehabilitation treatment.  He was considered a high-risk patient when drinking alcohol and using substances including physical aggression, blackouts and memory loss, medical issues including liver disease, legal problems, and worsened psychiatric symptoms including having a recent psychiatric hospitalization prior to this admission due to stopping psychotropic medications when he was drinking alcohol. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance rehabilitation treatment. It did not appear that the health care plan acted in the best interests of the individual then. 

The insurer's denial of coverage for the continued inpatient substance use rehabilitation treatment is overturned. Medical Necessity is substantiated.