Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse.
Treatment:  Inpatient rehabilitation.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This adult old male reportedly was admitted to this inpatient substance rehabilitation treatment center after an inpatient detoxification with Librium due to alcohol use. He reportedly was drinking 1 liter of whiskey per day and 12 beers daily and had reports of blackouts. He reportedly had multiple past treatment episodes and attempts including 10-13 relapses and attempts at treatment and sobriety. His longest reported sobriety was 3 years. It was reported that his addiction interfered with his ability to maintain employment. He reportedly was depressed and had not talked to his mother. He reportedly also had a significant medical history for hypertension, asthma, and GERD. He reportedly attended group and individual therapy. He reportedly left against medical advice (AMA) after 10 days.

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  lacked sufficient coping skills and relapse prevention skills to remain abstinent in an ambulatory setting. He reportedly was at risk for severe, complicated and life threatening withdrawal due to his large amount of daily alcohol use. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he reportedly was using large amounts of alcohol daily which put him at risk for more severe, complicated, and even life threatening withdrawal, as well as risk for medical consequences to alcohol, and also interfered with his ability to maintain employment. He reported blackouts which put him at risk as well. 

He reportedly was treated for inpatient alcohol detoxification just prior to this inpatient substance rehabilitation treatment. He reportedly had multiple past treatment episodes and attempts including 10-13 relapses and attempts at treatment and sobriety, so he required inpatient substance rehabilitation treatment. He reportedly lacked the motivation, insight, coping skills, relapse prevention skills, and ability to identify relapse triggers, and lacked enough sober supports, so he required this inpatient substance rehabilitation treatment. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, he likely would have relapsed immediately as evidenced by multiple past relapses after past treatments. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for substance abuse inpatient rehabilitation is substantiated.