Appeal type: Medical necessity
Decision: Overturned

Diagnosis: substance abuse

Treatment: inpatient rehabilitation treatment

The insurer denied coverage for inpatient rehabilitation treatment
 
The denial is overturned.

This adult male was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation treatment. He reportedly was smoking 4 bags of crack/cocaine per day and also smoking 1 joint of PCP (phencyclidine) a few times per month. He had a positive toxicology for cocaine and PCP. He reportedly had multiple past failed treatment attempts including an inpatient substance rehabilitation treatment. He reportedly was in outpatient substance treatment and reported no clean time ever when outside of a 24-hour setting. He reportedly also had comorbid psychiatric issues including a diagnosis of schizoaffective disorder-bipolar type and past psychiatric hospitalizations. He reportedly took Risperidone and Depakote for psychiatric reasons. He reportedly was unemployed and lacked sufficient sober supports. He reportedly had past legal issues including past prison time. He reportedly attended group therapy to try to improve coping skills, identification of relapse triggers, improve insight, and relapse prevention skills. He reportedly was discharged and referred back to outpatient substance treatment then.
  
The insurer denied coverage for inpatient substance rehabilitation treatment as not medically necessary treatment then. They stated that he did not have medical or mental health concerns requiring 24-hour inpatient substance rehabilitation treatment then, and they recommended a less restrictive level of care then.
  
The medical records provided enough specific evidence to support that he required this level of care. The APA (American Psychiatric Association) 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 reportedly was using large amounts of crack/cocaine daily and also used PCP which put him at risk medically and psychiatrically. He reportedly lacked the coping skills and ability to identify relapse triggers to stop use and had no reported clean time. 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 a serious substance of use, crack/cocaine daily and also used PCP despite multiple past treatment episodes, including an inpatient substance rehabilitation treatment and he was currently relapsing while in outpatient substance treatment. 
The goal was for him to learn better coping skills, improve insight into use, and to better identify relapse triggers, as well as identify how his mental illness contributed to his substance use. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting then. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly as evidenced by relapsing after past inpatient substance treatment and past substance treatment episodes. He was considered at risk medically and psychiatrically due to his large amount of crack/cocaine use and PCP use while having a diagnosis of schizoaffective disorder-bipolar type. 

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 substance use inpatient rehabilitation treatment, is overturned. Medical Necessity is substantiated.