Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: continued inpatient substance use rehabilitation treatment, revenue code 0128

The insurer denied coverage for continued inpatient substance use rehabilitation treatment, revenue code 0128

The denial is overturned.

This adult male patient was admitted to this inpatient mental health substance rehabilitation due to alcohol use problems. He reportedly was drinking up to 1.5 liters of alcohol per day. He reportedly had past blackouts and suspicion of delirium tremens (DT's). He reportedly had withdrawal symptoms including tremors, restlessness, agitation, and high blood pressure and a Clinical Institute Withdrawal Assessment (CIWA) of 11. The patient had Valium for detoxification and attended individual and group therapy for alcohol rehabilitation treatment. He reportedly had seen his primary care provider (PCP) who prescribed Vivitrol intramuscular (IM) for alcohol use problems. He reportedly had depressed mood, anxiety, and hopelessness. The patient reportedly had auditory and visual hallucinations when under the influence of alcohol. He reportedly lacked coping skills and insight for recovery. The patient had past inpatient substance/alcohol treatment for inpatient alcohol/substance rehabilitation treatment. He attended group and individual therapy and was discharged.
  
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 for the entire inpatient substance rehabilitation treatment stay as he could not stop drinking alcohol and reportedly was at risk for severe, complicated, and life-threatening withdrawals as there was suspicion of past DT's and he had active withdrawal symptoms on admission. He reportedly continued to use alcohol despite past inpatient alcohol treatments and Vivitrol IM shots and still relapsed and could not maintain abstinence. He reportedly lacked enough sober supports to maintain abstinence outside of this 24-hour substance rehabilitation treatment. 

The patient required more than just 2 days in this 24-hour alcohol inpatient treatment for detoxification and rehabilitation and required the full amount of time there until discharge. He reportedly needed time to try to improve coping skills, better identify relapse triggers, and needed to learn relapse prevention skills. He was unable to stop alcohol use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting and required the entire stay including as he was discharge. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly. 

This reviewer disagrees with the decision to deny coverage for continued inpatient mental health substance as the medical records provided enough specific evidence to support that he required this level of care. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the individual.

The insurer's denial of coverage for continued inpatient substance use rehabilitation treatment, revenue code 0128 is overturned. Medical necessity is substantiated.