Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Residential Substance Use Disorder Treatment

The insurer denied the Residential Substance Use Disorder Treatment. The denial was reversed.

This is a male patient who presented to an alcohol and substance rehabilitation facility after completing several days for treatment of substance detoxification. He had a history of cocaine use, snorted a 12 gram per day, snorting methamphetamine several times a week since 2017. He also reported that he used LSD a few times a year. It was documented that the patient lacked insight and admitted to losing several jobs due to his addictions. During his detoxification process his symptoms included agitation, restlessness, anxiety, headache, bone and joint aches, poor sleep, nightmares and dreams, and impaired concentration, mood swings, irritable mood, rapid speech, and high cravings. He was transferred to a rehabilitation facility for continued treatment.

The 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.

According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he continued to use multiple substances and alcohol despite negative consequences including impaired functioning occupationally as he lost multiple jobs reportedly due his use including current unemployment and had interpersonally difficulties. He reportedly lacked coping skills to maintain abstinence, had severe cravings, needed to better identify relapse triggers, and needed motivation for change and to build sober supports and develop relapse prevention skills. He was unable to stop substance and alcohol use without being in a sober and supervised therapeutic inpatient substance residential setting then. Without this structured and supervised therapeutic residential treatment he likely would have relapsed quickly and had more negative consequences due to use. It also was reported that he lived with his parents and his father drank alcohol and that he was not happy with his current living situation. The notes reported that he was working on better communicating, improving coping skills, and were using meditation techniques. 

Later notes reported that he was working through anxiety and a stressor, including that his brother was assaulted. Notes from the middle of his admission reported that he was anxious and confronted about his smoking cigarettes off grounds, and he spoke about the destructiveness of not changing behavior in recovery and how it could lead to relapse. He also reported that he still wanted to drink alcohol when in a bad mood which was another trigger and made it more likely that he would relapse. In later notes from of his admission it was reported that he was working on decreasing anxiety and improving coping skills, and using mindfulness. Notes from his last days at treatment reported that he was working on dealing with perceived criticism. 

Based on the above, the medical necessity for the Residential Substance Use Disorder Treatment is substantiated. The insurer's denial is reversed.