Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: 11 units of inpatient substance use rehabilitation treatment, revenue code 0128
The insurer denied coverage for 11 units of inpatient substance use rehabilitation treatment, revenue code 0128. 
The denial is reversed.

This patient is a male patient who was admitted to inpatient substance rehabilitation treatment after an inpatient substance detoxification treatment stay in which the patient had Librium and Methadone detoxification medication due to an initial Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 17 and Clinical Opiate Withdrawal Scale (COWS) score of 18. The patient's past history was significant for a few past inpatient substance treatments including detoxification inpatient treatment. The patient reportedly lived alone. During inpatient stay, the patient attended individual and group therapy, and worked on identifying relapse triggers, improving insight into use and consequences of use, relapse prevention skills, and overcoming guilt over his relapse. The patient chose to return home and attend self-help groups instead of outpatient substance treatment, and the patient was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient substance rehabilitation 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. These facilities provide a safe and substance-free environment in which patients learn individual and group living skills for preventing relapse. In this case, this patient was considered in need of 24-hour inpatient substance rehabilitation treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as he continued to use serious substances including large amounts of heroin up to multiple bags per day and several packs of beer per day despite multiple past inpatient substance detoxification treatments. The patient continued to relapse and was unable to maintain abstinence. This provides support that this patient required a sober and supervised structured therapeutic inpatient substance rehabilitation treatment setting to give this patient the best chance of working on improving coping skills, better identify relapse triggers, work on guilt, improving insight into use and consequences to use, and improve relapse prevention skills.

Based on the literature review, it was appropriate and standard treatment for this patient to be stepped down from an inpatient substance detoxification to an inpatient substance rehabilitation treatment as the patient was at high risk for relapse if the patient was not in this intensive and structured therapeutic inpatient substance rehabilitation treatment. The patient lacked coping skills and needed to better identify relapse triggers and develop relapse prevention strategies. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, the patient would have likely relapsed quickly again. As a result, this patient's inpatient substance rehabilitation treatment was medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for the 11 units of inpatient substance use rehabilitation treatment, revenue code 0128 should be reversed. The medical necessity is substantiated.