Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use. 
Treatment: Residential Treatment Center Care.

The insurer denied coverage for the Residential Treatment Center Care.  The denial is overturned. 

This is a male patient who was admitted to inpatient substance residential treatment for alcohol rehabilitation. He reportedly was drinking more alcohol with increased frequency. He had hypertension, gastroesophageal reflux disease (GERD), and diabetes. He reportedly continued to drink increased amounts and frequency of alcohol despite his reports of past outpatient substance treatment. He attended individual, group, and family therapy prior to discharge. 

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 for the time period under review as he was using larger amounts of alcohol more frequently and it interfered with both occupational and interpersonal functioning.  He reportedly was observed to be slurring his speech at work and was suspended for reports of alcohol intoxication while at work. It was reported that he was drinking alcohol late the night before. He also had a marital separation and was living separate from his young son due to alcohol use. He reportedly could not stop use on his own although he tried. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance rehabilitation treatment as he continued to use larger amounts of alcohol more frequently despite negative consequences including being suspended from his occupation and also was separated from his wife and child. He reportedly lacked coping skills to maintain abstinence, needed to better identify relapse triggers, needed motivation for change, needed sober supports, better decision making and impulse control, and needed to develop relapse prevention skills. He was unable to stop alcohol use without being in a sober and supervised therapeutic inpatient substance residential setting then. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment he likely would have relapsed quickly and had more negative consequences due to use. The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide - reports that the best treatment outcomes occur with longer durations of treatment. It also states that recovery from drug addiction is a long term process and that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. 

This patient required this 24-hour rehabilitation treatment, as he was at high risk to continue use of alcohol and at higher amounts. He required this 24-hour therapeutic substance rehabilitation treatment setting to develop the necessary skills for abstinence. He continued to be at high risk for relapse and required the structured and supervised therapeutic rehabilitation setting then. 

Inpatient substance rehabilitation treatment for the time period under review was medically necessary. It did not appear that the health care plan acted reasonably or in the best interests of the individual.

The carrier's denial of coverage for the Residential Treatment Center Care is overturned. The medical necessity is substantiated.