Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse. 
Treatment: Admission at a substance abuse inpatient detoxification level of care. 

The insurer denied coverage for admission at a substance abuse inpatient detoxification level of care. 

The denial is overturned. 

This adult patient was admitted to inpatient rehabilitation/detoxification treatment due to alcohol and cocaine use. The patient had a diagnosis of Alcohol Use Disorder and Cocaine Use Disorder. The patient had a positive toxicology for cocaine and benzodiazepines. The patient had in excess of 20 past inpatient detoxification treatments and 7 inpatient rehabilitation treatments and left some Against Medical Advice (AMA). The patient reportedly lacked the coping skills to maintain abstinence. The patient reportedly attended group therapies. The original plan was to go to an inpatient substance residential treatment long term after completing this inpatient substance/alcohol rehabilitation/detoxification treatment but there were no available beds, so the patient was discharged to outpatient treatment. 

The reviewer disagrees with the decision to deny coverage for inpatient rehabilitation/detoxification treatment as the medical records for review did provide enough specific evidence to support that the patient required inpatient habilitation/detoxification 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 the patient lacked the coping skills and substance-free social supports to remain abstinent in an ambulatory setting as evidenced by the fact that the patient had no significant abstinence time reported despite an excess of 20 past inpatient substance detoxification treatments and 7 inpatient substance rehabilitation treatments and was considered a high-risk patient for relapse. 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 reportedly was using large amounts of alcohol daily including drinking half a pint of vodka and five 24-ounce beers per day and was using cocaine daily. The patient required inpatient substance/alcohol detoxification treatment first due to the risk of more severe withdrawal due to the large amount of daily alcohol, cocaine use and the need for inpatient alcohol/substance rehabilitation treatment to learn better coping skills, identification of relapse triggers, increase sober supports, improve motivation, learn relapse prevention skills, and maintain abstinence. Without this structured and supervised therapeutic inpatient substance rehabilitation/detoxification treatment, the patient likely would have relapsed immediately as evidenced by the past history of relapsing after over 20 past inpatient detoxification treatments, 7 inpatient rehabilitation treatments and the inability to maintain abstinence. The patient was considered at risk for severe withdrawal, medical issues, and the patient was unable to maintain abstinence. 

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 the admission at a substance abuse inpatient detoxification level of care is substantiated.