Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use

Treatment: Residential substance use treatment

The insurer denied coverage for residential substance use treatment. The denial is overturned.

This patient is a male was admitted to this inpatient substance residential treatment for substance and alcohol rehabilitation treatment. He was using intravenous heroin 2 grams and drinking whiskey. He was taking 5 Zubsolv tablets by snorting and had recent cocaine use consisting of 1 ball. He had legal issues, relapses after prior inpatient substance treatments, and had prior reported withdrawal symptoms. He had depression and anxiety and was also taking Lexapro, Remeron, and melatonin. It was reported that he also took Naltrexone. His longest reported abstinence was several months when he took Vivitrol. He attended groups and was discharged to Footprints to Recovery.

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 level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but 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. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. In this case, this patient was considered in need of continued 24 hour residential treatment as he needed more time in this 24 hour inpatient therapeutic structured and supervised setting to learn more coping skills, relapse prevention skills, improve insight, better identify triggers, improve motivation, and learn the reasons for past relapses.  He could not stop using substances including heroin, Zubsolv, cocaine, and alcohol despite negative consequences of use and past inpatient substance treatments.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance residential rehabilitation treatment as he continued to use multiple serious substances and alcohol despite the negative consequences of substance use such as legal issues. He could not stop using multiple substances without the 24 hour therapeutic, supervised and structured programming of this therapeutic residential treatment setting. Notes reported that he needed to work on decreasing depression, anxiety, and cravings, work on distress tolerance and emotional regulation techniques, and needed education on relapse prevention. Notes reported that he was working on recovery skills. Notes reported that he was working on triggers, reasons for past relapses, coping skills, and relapse prevention skills. The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide reports that research indicates that that the best treatment outcomes occur with longer durations of treatment and states that recovery from drug addiction is a long term process. As a result, reverse the previous decision and approve coverage for continued inpatient substance residential rehabilitation treatment. The health care plan did not act reasonably, or with sound medical judgment, or in the best interests of the patient. 

Based on the above, the medical necessity for residential substance use treatment is substantiated.  The insurer's denial is overturned.