Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse.
Treatment:  Inpatient substance abuse admission.

The insurer denied coverage for inpatient substance abuse admission.  The denial is overturned.

This adult patient was admitted to inpatient substance rehabilitation treatment. He reportedly was using $100 per day of crack/cocaine, drinking a 6 pack of beer daily, and using $10 per day of cannabis. He reportedly requested inpatient substance rehabilitation in order to learn better coping skills to achieve sobriety and needed a structured environment to assist in this. He reportedly had diagnoses of Cocaine Use Disorder, Cannabis Use Disorder, and Alcohol Use Disorder. He reportedly was unemployed. He had a positive toxicology for cocaine and tetrahydrocannabinol (THC). He had past inpatient substance detoxification and rehabilitation treatments and still was unable to maintain sustained abstinence. He attended group therapy including mindfulness to try to learn better coping skills for abstinence. 

The medical records provided enough specific evidence to support that he required this inpatient 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 serious substances daily including $100 per day of crack/cocaine and a six pack of beer daily as well as $10 worth of cannabis daily. This put him at risk of medical consequences to cocaine use and also at risk for overdose and for alcohol withdrawal. He reportedly lacked the coping skills and ability to identify relapse triggers to stop use. 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 cocaine, cannabis, and alcohol use despite multiple past inpatient substance treatments and a past inpatient substance rehabilitation treatment, and still relapsed and could not maintain abstinence. He reportedly had a substance using social network which contributed to his relapse and continued use. He reportedly lacked enough sober support to maintain abstinence outside of this 24-hour supervised and structured inpatient substance rehabilitation treatment as he was considered a high risk to continue use. He reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting then. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly again. 

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 the inpatient substance abuse admission is substantiated.