Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: Inpatient rehabilitation.
The insurer denied coverage for inpatient rehabilitation.
The denial is overturned.

This adult patient was admitted to this inpatient substance rehabilitation treatment due to alcohol, crack, and cannabis use. She reportedly had last used the day of admission. She had a long history of alcohol use and cannabis use. She was living in a shelter and lacked community support. She had many past inpatient substance detoxification treatments and rehabilitation treatments and could not maintain abstinence when discharged from those treatments. She had comorbid psychiatric conditions including bipolar disorder and anxiety disorder and was noncompliant with psychotropic medication. She lacked coping skills for abstinence. She took Celexa and Seroquel. She attended group and individual therapy but left against medical advice.
  
The insurer denied coverage for inpatient substance rehabilitation treatment and stated that it was not medically necessary treatment. They stated that there were no medical or mental health concerns requiring 24-hour treatment or preventing treatment in a less restrictive level of care then.
  
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 she required this level of care. 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 as she reportedly was using large amounts of alcohol daily including 2 pints of vodka and was using serious substances of use including crack and cannabis which put her at risk medically and also for severe, complicated, and life-threatening withdrawals. She reportedly lacked the coping skills and ability to identify relapse triggers to stop use.

Also, the National 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 the entire time in this therapeutic structured and supervised inpatient rehabilitation treatment. Without this structured and supervised therapeutic rehabilitation treatment she likely would have relapsed immediately as evidenced by relapsing after multiple past inpatient substance/alcohol treatments.

Based on the above, the insurer's denial must be overturned. 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 substance use inpatient rehabilitation treatment is substantiated.