Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Hospital admission at a substance abuse inpatient level. 

The insurer denied coverage for hospital admission at a substance abuse inpatient level. 

The denial is overturned. 

This patient was admitted to inpatient substance rehabilitation treatment for substance rehabilitation treatment. For many years, he was using 5-10 bags of intravenous (IV) heroin daily, $20 of intranasal cocaine twice per week, and 2-3 joints of marijuana daily with. He had a positive toxicology for opiates, cocaine, THC (Tetrahydrocannabinol), and methadone. He reportedly had withdrawal symptoms including diarrhea, hot and cold sweats, sleeping problems, and anxiety symptoms. He reportedly had 5 past inpatient detoxification or rehabilitation treatments and reportedly had a recent inpatient detoxification treatment. He was unemployed. He reportedly had no abstinence. He left against medical advice (AMA). 

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. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of IV heroin daily, $20 of intranasal cocaine twice per week, and 2-3 joints of marijuana and cannabis daily and could not maintain any abstinence. He had no clean time. He reportedly continued to use large amounts of opiates putting him at high risk for accidental overdose. He had a positive toxicology for opiates, cocaine, THC, and methadone. He also had withdrawal symptoms including diarrhea, hot and cold sweats, sleeping problems, and anxiety symptoms. 

The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that the best treatment outcomes occur with longer durations of treatment. It also states that recovery from drug addiction is a long-term process and that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. In this case this patient required inpatient substance rehabilitation treatment setting but left AMA. He required this sober, structured and supervised therapeutic inpatient substance rehabilitation setting for substance rehabilitation. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly again and been more at risk medically for overdose due to the large amount of heroin use daily as well as cocaine use. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient substance rehabilitation treatment. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the individual. 

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 a hospital admission at a substance abuse inpatient level of is overturned. Medical Necessity is substantiated.