Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use. 
Treatment: 14 days/units of room and board semi-private (2 beds) rehabilitation.

The insurer denied coverage for 14 days/units of room and board semi-private (2 beds) rehabilitation.  The denial is overturned. 

This is a male patient admitted for inpatient substance/alcohol rehabilitation treatment after completing inpatient substance/alcohol detoxification.  The patient reportedly had a history of alcohol withdrawal seizures and also had a positive toxicology for benzodiazepines.  The patient reported drinking 2 pints of vodka per day, and had multiple past inpatient substance/alcohol detoxification and rehabilitation treatments including 6 inpatient rehabilitation treatments, 4 outpatient treatments, and a residential treatment.  The patient's psychiatric history was also significant for schizoaffective disorder-bipolar and was taking psychotropic medications including quetiapine, Depakote, sertraline, and had Ativan as needed in case of detoxification needs and also Campral for alcohol use treatment.  The patient was homeless and was living in a shelter.  The patient's comorbidities included alcohol withdrawal seizures, gastroesophageal reflux disease (GERD), osteoarthritis, and gait problems.  As per medical record, the patient was disruptive on the unit and was noncompliant, and was discharged administratively.

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 inpatient rehabilitation treatment.  The patient had comorbid medical and psychiatric issues putting him at further risk including his diagnosis of schizoaffective disorder-bipolar as he was taking multiple psychotropic medications and medical history including alcohol withdrawal seizures, GERD, osteoarthritis, and gait problems.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as he continued to use alcohol and benzodiazepines despite multiple past inpatient substance rehabilitation and detoxification inpatient treatments, a past residential treatment, and multiple outpatient treatments, so he required at least this inpatient substance/alcohol rehabilitation treatment then.  The patient also lacked supports and was homeless.  Also, the patient continued to use alcohol and substance use despite negative consequences including past legal issues including a history of incarceration.  The patient reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills.  The patient was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting then.  Without this structured and supervised therapeutic rehabilitation treatment, the patient likely would have relapsed quickly as evidenced by his history of past relapses after inpatient treatment.  Even though the patient was administratively discharged for disruptive and noncompliant behavior, the patient still required this intensive substance/alcohol rehabilitation treatment. 

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

The carrier's denial of coverage for 14 days/units of room and board semi-private (2 beds) rehabilitation should be overturned.  The medical necessity is substantiated.