Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient rehabilitation

The insurer denied coverage for inpatient rehabilitation

The denial is overturned.

This male reportedly was admitted to inpatient substance rehabilitation treatment for substance rehabilitation treatment due to cocaine and cannabis. He reportedly had diagnoses of bipolar disorder and PTSD and was taking Depakote and Vistaril. He reportedly had poor coping skills, difficulty identifying relapse triggers, cravings, lacked insight and judgment, and motivation issues. He reportedly attended individual and group therapy and 12 step groups. 
   
This reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment from as the medical records did provide 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 from as he reportedly was using large amounts of cocaine and cannabis and had comorbid psychiatric bipolar disorder and PTSD (post-traumatic stress disorder). He reportedly lacked the coping skills and ability to identify relapse triggers to stop use and reportedly could not maintain any abstinence. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of substances daily putting him at risk medically and for withdrawal despite past treatment. He reportedly lacked coping skills to maintain abstinence outside of this 24-hour substance rehabilitation treatment and needed to better identify relapse triggers and to learn relapse prevention skills as well as increase sober supports. It was reported that his use of substances was interfering with his functioning and put him more at risk for worsened psychiatric symptoms and danger to self. He still reportedly had drug dreams and cravings for substances, difficulty maintaining housing and employment, and was spending more time and money on using substances. 

Also, 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. It also states that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. He required at least this time in this 24-hour inpatient substance rehabilitation treatment. 

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

The insurer's denial of coverage for the inpatient is overturned. Medical Necessity is substantiated.