Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use

Treatment: Residential substance use treatment admission

The insurer denied coverage for residential substance use treatment admission. The denial reversed.

This patient is a male who was admitted to this inpatient substance residential treatment for inpatient substance detoxification with a Librium protocol. He had a
2-decades history of substance use.  He was using Xanax and Klonopin, as well as Fentanyl and Roxicodone.  He had an overdose two months prior to this admission. He had withdrawal symptoms including nausea, vomiting, sweating, stomach cramping, anxiety, irritable mood, and runny nose with a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 9.  He had a Librium protocol and was admitted for substance rehabilitation.  He had a history of 10+ past inpatient substance treatments and had diagnoses of Sedative Use Disorder and Opiate Use Disorder.  He also had a reported diagnosis of Unspecified Anxiety Disorder.  He took Tegretol, Clonidine, and Buprenorphine which was discontinued.  It was reported that sober living was recommended upon discharge, but he was discharged back to his apartment. 

The insurer denied coverage for continued inpatient substance residential treatment as not medically necessary treatment. This reviewer disagrees with the decision to deny coverage for continued inpatient substance residential treatment as the chart notes provided enough specific evidence to support that he required this 24-hour inpatient substance residential rehabilitation 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.  

In this case, this patient was considered in need of 24-hour substance rehabilitation treatment as he was using multiple serious substances including Xanax and Klonopin, as well as Fentanyl and Roxicodone.  He was at risk for another overdose and was also considered at risk for severe and life-threatening complicated withdrawal due to the use of multiple serious substances including opiates and benzodiazepines.  Additionally, he had an overdose two months prior to admission.  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 multiple substances despite multiple past inpatient substance treatments including 10+ inpatient substance treatments.  
He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance residential setting.  Also, the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that research indicates that most addicted individuals need at least three months in treatment to significantly reduce or stop their drug use and that the best treatment outcomes occur with longer durations of treatment.  

As a result, reverse the previous decision and approve coverage for continued inpatient substance residential treatment.  The health care plan did not act reasonably or with sound medical judgment or in the best interests of the patient.

The carrier's denial of coverage for the residential substance use treatment admission is reversed.  The medical necessity is substantiated.