Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Polysubstance abuse.
Treatment:  Residential Substance Use Treatment.

The insurer denied coverage for Residential Substance Use Treatment.  The denial is overturned.

This is a male patient, who was admitted for inpatient substance residential treatment for 24-hour therapeutic inpatient treatment, due to his significant alcohol, heroin, and cocaine use.  The patient reportedly was drinking 12 beers per day, using 4-5 bags of intravenous (IV) heroin per day, and smoking 2-3 grams of cocaine per day.  The patient reportedly had past legal issues and jail time.  The patient also had marital discord.  The patient reported having 9-10 inpatient detoxification or rehabilitation treatments in the past.  His longest reported recent abstinence was 16 months.  The patient also had medical conditions, such as hepatitis C viral infection, and lacked coping skills for recovery.  The patient was in a recent inpatient substance setting and was then admitted for this 24-hour alcohol and substance rehabilitation 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.  Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse.  

In this case, this patient was considered in need of 24-hour residential treatment then with his recent relapse after receiving 9-10 inpatient substance treatments in the past.  The patient was at a high risk for overdose and life-threatening withdrawal symptoms with his polysubstance use.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance residential rehabilitation treatment, as he continued to use multiple serious substances of use despite multiple past inpatient substance treatments and despite negative consequences of substance use including legal problems and past jail time, medical consequences to use including hepatitis C, and marital discord.  The patient reportedly did not have the ability to make behavioral changes with the reported structure and supervision of this residential treatment.  The patient also had a history of past victimization issues.  The patient's clinical presentation required more than the one week in his previous inpatient setting to learn better coping skills, identification of relapse triggers, work on relapse prevention skills, improving impulse control and decision making, and increase sober supports.  Considering this patient's past substance history and current use of multiple substances despite legal, health and marital issues, inpatient substance residential treatment was medically necessary for this patient's safety and to provide effective treatment care.

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 Residential Substance Use Treatment should be overturned.  The medical necessity is substantiated.