Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient rehabilitation

The insurer denied coverage for inpatient rehabilitation.

The denial is overturned.

This patient reportedly was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation treatment. The patient reportedly was using multiple serious substances of use including drinking 1 quart of liquor per day, smoking $200 of crack/cocaine daily, using 2 bags of heroin 1-2 times per week, and using 500 milligrams of edible tetrahydrocannabinol (THC) 1-3 times per week. The patient reportedly had a long history of use including 25 years for THC use, 19 years for heroin use, and 5 years for alcohol use. The patient reportedly had 4 past overdoses including a recent one 1 month prior to admission. The patient reportedly had 25 past substance use treatments including past inpatient rehabilitation, residential, and detoxification treatments. The patient reportedly had elevated heart rate, nausea, and sweats. The patient reportedly had a recent inpatient detoxification treatment and was treated with detoxification medications then including Phenobarbital, Lorazepam, and Librium. The patient reportedly had a significant family history for alcohol and substance use. The patient reportedly was homeless and unemployed. The patient reportedly had a positive toxicology for benzodiazepines, Oxycodone, and THC. The patient reportedly attended individual and group therapy as the patient reportedly lacked coping skills for abstinence. The patient reportedly was transferred to a less restrictive level of care as the patient went to a substance abuse residential treatment.
  
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. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient met criteria for inpatient substance rehabilitation treatment as the patient continued to use large amounts of substances daily putting them at risk medically and for severe withdrawal despite 25 past treatments including inpatient rehabilitation, residential, and detoxification treatment. The patient reportedly still was unable to maintain abstinence despite these past treatments including past inpatient rehabilitation treatment, so the patient required at least that level of care during this treatment episode. The patient reportedly lacked coping skills to maintain abstinence outside of this 24-hour substance rehabilitation treatment and needed to better identify relapse triggers and to learn relapse prevention skills as well as increase sober supports as the patient reportedly was homeless and unemployed with a significant family history of substance/alcohol use. The patient reportedly could not be managed at a less restrictive level of care as the patient could not even maintain abstinence after being treated in a past inpatient substance rehabilitation treatment so it was not likely that the patient could effectively be treated in a less restrictive level of care then. The patient reportedly could not stop multiple substances of 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 as evidenced by relapses after other inpatient substance treatment settings. 

Based on the above, the insurer's denial must be reversed. 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 Abuse Inpatient Rehabilitation is substantiated.