Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.
Treatment: inpatient substance rehabilitation treatment.
The insurer denied coverage for inpatient substance rehabilitation treatment.
The denial is overturned.

This male reportedly was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation treatment. He reportedly was using 3 bars of Xanax daily, smoking $100 of crack 3-6 times per week, and using cannabis. He had a positive toxicology screen for cocaine, THC (tetrahydrocannabinol), and methamphetamine. He reportedly lost his employment one month prior to admission due to stealing on the job. It was reported that his significant other would not talk to him until he attended inpatient substance rehabilitation treatment. He reportedly had 5 past unsuccessful treatment episodes including past inpatient substance residential treatment and past outpatient and intensive outpatient substance treatment. He reportedly had a recent substance detoxification treatment 2 weeks prior to admission. He reportedly was living alone and living in a drug infested community. He reportedly was isolating from his family, had depression and anxiety, decreased appetite and weight loss, sleeping problems, and had experienced recent losses. He reportedly had drug dreams, cravings, anger, and irritability. He reportedly had medical issues including hepatitis C, cirrhosis, and respiratory distress. He reportedly had past legal issues for selling drugs. He reportedly attended group therapy and took Vistaril and Melatonin.

This reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment, the medical records provided enough specific evidence to support that he required this level of care then. 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 reportedly was using large amounts of Xanax daily, cocaine 3-6 times per week and using cannabis. He reportedly could not stop use despite past inpatient substance detoxification and rehabilitation treatments and past outpatient substance treatments. He lacked the coping skills and ability to identify relapse triggers to stop use and reportedly could not maintain any abstinence.

He reportedly could not stop multiple substances of use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting then. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly as evidenced by relapses after other inpatient substance treatment settings including a recent inpatient substance detoxification treatment 2 weeks prior to this admission. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance rehabilitation treatment. It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the individual then.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the substance abuse inpatient rehabilitation admission is overturned. Medical Necessity is substantiated.