Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance and alcohol use 
 
Treatment: Inpatient substance rehabilitation

The insurer denied coverage for inpatient substance rehabilitation. The denial is reversed. 

This patient is a male was admitted to inpatient substance rehabilitation treatment after a detoxification. He reportedly was found unresponsive after drinking 1 liter if vodka and taking Xanax and went to the Emergency Department (ED).  He then had reports of withdrawal symptoms including sweats, tremors, increased heart rate, and agitation and was given Librium in the ED.  He then took Ativan for detoxification after that prior to inpatient rehabilitation.  He reportedly could not maintain abstinence despite multiple past treatments.  He lacked a sober support and lived alone and was isolative. He reportedly was taking Propranolol for increased heart rate and anxiety.  He reportedly was working on better identification of relapse triggers, improving insight and coping skills as well as impulse control and decision making.  

The insurer denied coverage for inpatient substance rehabilitation treatment. His reviewer disagrees with the decision to deny coverage for rehabilitation treatment as the chart notes provided enough specific evidence to support that he required this 24 hour residential treatment.  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 was using multiple substances including large amounts of alcohol and Xanax which put him at high risk for overdose, and he reportedly was found unconscious and unresponsive on a specified date due to this which put him at serious risk of danger to self. He could not stop use on his own.

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 alcohol daily with the benzodiazepine Xanax despite negative consequences including legal arrests, driving under the influence, and being found unconscious and unresponsive.  He was considered a high risk patient with lack of supports who lived alone.  He reportedly lacked coping skills to maintain abstinence, needed to better identify relapse triggers, needed motivation for change, needed sober supports, better decision making and impulse control, he needed to develop relapse prevention skills. The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- report 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 this 24 hour rehabilitation treatment as he was at high risk to continue use alcohol and Xanax without this 24 hour therapeutic substance rehabilitation treatment setting and needed to develop the necessary skills for abstinence.  

The carrier's denial of coverage for the substance use rehabilitation is reversed.  The medical necessity is substantiated.