Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol use disorder, cannabis use disorder and tobacco use disorder.

Treatment residential rehabilitation treatment.

The insurer denied coverage for residential rehabilitation treatment.

The denial is overturned.

This is the case of a male patient who was in inpatient substance residential rehabilitation treatment and had an initial psychiatric evaluation. The patient had a diagnosis of alcohol use disorder and cannabis use disorder. He reportedly was homeless and had been unemployed for a long period of time. He reportedly had limited supports and was isolative. He reportedly had trust issues due to trauma and losses including recent deaths of his father and brother. He had negative urine toxicologies. The patient reportedly had depression, sleeping problems, low energy, and had some medication noncompliance with his diabetes medication. He was taking Bupropion, Seroquel, Trazodone, Amitriptyline, and Hydroxyzine. The patient was attending groups. 

The insurer denied coverage for continued inpatient substance residential rehabilitation treatment as not medically necessary treatment. They stated that he was actively participating in treatment, had no severe urges or cravings, or withdrawal symptoms, and had no acute medical or psychiatric conditions requiring 24 hour inpatient residential treatment. 
 
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 time in this 24-hour inpatient therapeutic structured and supervised setting to learn coping skills, relapse prevention skills, improve insight, better identify triggers, improve motivation, improve relapse prevention skills and sober supports. 

In this case this patient required the treatment time as requested, as he was not ready to be discharged from this 24-hour residential treatment and needed more time to further progress and decrease the chances of relapse when outside of this residential setting. He needed the entire time in this sober therapeutic 24-hour residential rehabilitation treatment in order to develop relapse prevention skills, strengthen coping skills, decrease impulsivity, better identify triggers, improve relapse prevention skills and insight, and sober supports. He reportedly was homeless and had limited sober supports. Without this structured and supervised therapeutic residential treatment, he likely would have relapsed, so he required this 24-hour therapeutic inpatient substance residential treatment for another month as requested. 

Continued inpatient substance residential rehabilitation treatment for an additional month is medically necessary as the medical records provided enough specific evidence to support that he required inpatient substance residential rehabilitation treatment. If he were still in treatment, the recommendation is for the insurer to do another review to assess further treatment needs and progress. 

It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the individual.

The insurer's denial of coverage for residential rehabilitation treatment is reversed. Medical necessity is substantiated.