Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder

Treatment: Inpatient rehabilitation admission

The insurer denied coverage for inpatient rehabilitation admission

The denial is overturned 


This adult female was admitted to inpatient substance rehabilitation treatment for inpatient substance rehabilitation treatment. She reportedly was using 1 bag of intranasal heroin per day and had a 16 year history of use. She was court mandated by the Bronx Treatment Alternatives to Street Crime (TASC) force for treatment. She reportedly was still using heroin despite being in treatment in an outpatient facility and being in a Methadone Maintenance Treatment Program (MMTP) and receiving 60 mg of Methadone per day. Her toxicology was positive for opiates and methadone. She reportedly had past inpatient substance rehabilitation treatment and could not maintain abstinence and relapse. She reportedly lacked coping skills and support to remain abstinent. It was reported that she was living with her husband who was in recovery. She reportedly had comorbid bipolar depression and had a reported history of past suicide attempts including jumping off a roof and overdose. She reportedly attended group therapy for relapse prevention, addiction education, stress management, Medication Assisted Therapy (MAT) education, and anger management. She reportedly completed the program and was referred back to her outpatient substance treatment program and Methadone Maintenance Treatment Program (MMTP).

The insurer denied coverage for inpatient substance rehabilitation treatment. They stated that she did not have social, emotional, or developmental barriers to participate in treatment outside of inpatient level of care. They also stated that she did not have co-occuring psychiatric or medical conditions requiring only inpatient level of care. They recommended a less restrictive level of care.

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 lacked sufficient coping skills and relapse prevention skills, ability to identify triggers, insight, and sober supports to remain abstinent in a less restrictive setting. She reportedly was at risk for severe withdrawal due to her daily heroin use and also was at risk for overdose. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she met criteria for inpatient substance rehabilitation treatment as she reportedly was using intranasal heroin daily which put her at risk for more severe withdrawal or overdose, and she reportedly was treated for past inpatient substance rehabilitation treatment and relapsed on a Methadone Maintenance Treatment Program (MMTP), so she required at least another inpatient substance rehabilitation treatment. She had comorbid bipolar depression and had a reported history of past suicide attempts, so she was considered at higher risk for suicide due to these multiple past attempts. 

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 an admission at the substance abuse inpatient rehabilitation level of care is substantiated.