Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient admission for substance use disorder
The insurer denied coverage for the inpatient admission for substance use disorder.
The denial is overturned. 

This is a male patient with a history of substance abuse who was admitted to inpatient substance rehabilitation treatment after a step down from inpatient substance detoxification treatment. The patient reportedly was drinking 30, 12-ounce beers daily and using crack/cocaine 1-3 times per week. It was reported that the patient could not stop the large amount of alcohol use and crack/cocaine use despite past inpatient substance detoxification treatments. The patient lacked supports and was homeless and unemployed. The patient also lacked coping skills and had difficulty identifying triggers. The patient left Against Medical Advice (AMA) on day 3 of admission.

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 and a step down from inpatient detoxification treatment as he was considered a high risk patient medically due to past alcohol withdrawal seizures. The patient was more at risk for life-threatening withdrawal such as delirium tremens. The patient was using large amounts of alcohol daily including up to 30 beers per day as well as crack/cocaine use which put him at risk medically especially with his history of cardiac disease. The patient 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), the patient met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol and also crack/cocaine despite past inpatient substance treatments including past inpatient substance detoxification treatments. The patient lacked sober supports to maintain abstinence outside of this 24-hour substance rehabilitation treatment as he was homeless and unemployed, lacked coping skills and ability to identify relapse triggers so he was a high risk to continue use. The patient reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. The patient 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, the patient likely would have relapsed quickly.  

Thus, based on the review of the medical record and literature, inpatient substance rehabilitation treatment was medically necessary for this patient.

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 inpatient admission for substance use disorder should be overturned. The medical necessity is substantiated.