Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cannabis use.
Treatment: Residential substance use disorder treatment.

The insurer denied coverage for residential substance use disorder treatment.  The denial is overturned.

This patient was admitted to this inpatient substance residential treatment due to severe cannabis use. He was using large amounts of cannabis daily and had reports of hallucinations at times when using. He had cravings and could not cut down or stop use. His use also interfered with his ability to attend college as he was on a medical leave due to his use. He had withdrawal symptoms including irritable, anxious, and depressed mood, concentration and energy problems. He had comorbid suicidal ideation with a past plan to jump out a window. He had diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder. He took Duloxetine for anxiety and depression. He attended group and individual therapy and also had pain management. He was discharged after treatment.
   
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but 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 still in need of 24-hour residential treatment as he needed more time to learn better coping skills, relapse prevention skills, improve insight into his addiction including how his psychiatric comorbidities contributed to his addiction, identify relapse triggers, improve motivation, and increase sober supports.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance residential rehabilitation treatment as he continued to use increased frequency of marijuana despite negative consequences. He was having difficulty functioning as he had to take a leave of absence from college. He had comorbid psychiatric conditions including major depression and anxiety and past suicidal ideation with plan to jump out a window and he was taking Duloxetine to treat depression and anxiety. He also had comorbid pain contributing to his use. It was reported that he had poor concentration and memory issues as per notes. It was reported that the day prior to discharge he took Wellbutrin for depression and low motivation as well as executive functioning complaints. He was worried about legal proceedings which caused him to withdraw more in groups. He could not stop use or cut down use on his own. He had external motivation as his attorney recommended this treatment after his legal charges. He lacked accountability for his behavior and consequences to use. His longest reported abstinence was 45 days when he was with his parent during the beginning of the pandemic and quarantine. The Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that research indicates that that the best treatment outcomes occur with longer durations of treatment and states that recovery from drug addiction is a long-term process. It also states that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. In this case this patient required more treatment time in a 24-hour inpatient therapeutic residential treatment setting. At the time of the denial, he still had not obtained the skills needed to remain sober and was still working on them. If he were discharged prematurely, he was considered a high risk for relapse.  

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

The insurer's denial of coverage for residential substance use disorder treatment is overturned. Medical Necessity is substantiated.