Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This patient reportedly was admitted to this inpatient substance rehabilitation treatment at Cornerstone for substance and alcohol rehabilitation treatment. The patient reportedly was smoking $10-$20 per day of crack/cocaine 3-6 times per week with an 11-year history, drinking 1 pint of liquor and four 12 ounce beers 1-2 times per week with a 16 year history, using $10-$20 of phencyclidine (PCP) 1-2 times per week with a 13 year history, and smoking 2 marijuana joints 1-2 times per week. The patient's toxicology was reportedly positive for amphetamines and PCP. The patient reportedly had multiple past substance detoxification and rehabilitation treatments and still could not maintain abstinence. It was reported that the patient lacked sober supports or family supports and was homeless living in a shelter and was unemployed. It was reported that the patient had comorbid psychiatric issues including depression with past suicidal ideation and post-traumatic stress disorder (PTSD) symptoms. It was reported that the patient was expected to be in this treatment setting and then referred to a long-term substance residential treatment but instead the patient left against medical advice (AMA).

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 the patient 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 inpatient substance/alcohol rehabilitation treatment as the patient lacked sufficient coping skills and relapse prevention skills, ability to identify triggers, and sober supports to remain abstinent in a less restrictive setting then. The patient reportedly was at risk for medical issues due to their large amount of crack/cocaine use, PCP use, and alcohol use and also was at risk for overdose or medical complications from crack/cocaine and alcohol use. 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 reportedly was using multiple serious substances and alcohol in large amounts and frequency. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, the patient likely would have relapsed as evidenced by their inability to stop use, relapse after multiple past inpatient substance treatments, and due to their lack of coping skills and sober supports. 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 inpatient substance abuse rehabilitation treatment is substantiated.