Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient hospital admission at an inpatient rehabilitation level of care

The insurer denied coverage for inpatient hospital admission at an inpatient rehabilitation level of care

The denial is overturned

This adult patient was admitted to the inpatient substance rehabilitation treatment for heroin, cocaine, and cannabis rehabilitation treatment. The patient reportedly was using intravenous (IV) heroin and cocaine daily with reported alcohol use and occasional cannabis use. The toxicology was positive for heroin, fentanyl, cocaine, and Tetrahydrocannabinol (THC). The patient reportedly had 10 relapse episodes, 7 detoxification treatments, and 1 inpatient rehabilitation treatment. The patient reportedly was in outpatient substance treatment prior to this, and they recommended inpatient rehabilitation treatment as the patient could not maintain abstinence. The patient's longest reported abstinence was 4 months. The patient had medical issues including hepatitis C. The patient reportedly was living alone, single and was employed. 

The reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment as the medical records for review did provide enough specific evidence to support that the patient required inpatient substance rehabilitation treatment. The American Psychological 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 support to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24-hour substance rehabilitation treatment as the patient lacked the coping skills and substance-free social support to remain abstinent in an ambulatory setting as evidenced by the fact that the patient had no significant abstinence time longer than 4 months.  

According to the Level of Care Determination (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as the patient reportedly was using and kept using multiple serious substances which put the patient at risk for overdose, medical issues, and severe withdrawal. The patient reportedly continued to use multiple serious substances despite 10 past relapse episodes, 7 detoxification treatments, and 1 inpatient rehabilitation treatment. The patient reportedly was in outpatient substance treatment prior to this, and they recommended inpatient rehabilitation treatment as the patient could not maintain abstinence without this inpatient therapeutic rehabilitation inpatient treatment setting. The patient lacked the motivation, insight, coping skills, relapse prevention skills, and the ability to identify relapse triggers, and lacked sober support. The patient required this inpatient substance rehabilitation treatment. Without this structured and supervised therapeutic inpatient substance rehabilitation/detoxification treatment, the patient likely would have relapsed immediately as evidenced by the past history of relapsing after multiple past inpatient detoxification treatments and one inpatient rehabilitation treatment and the inability to maintain abstinence while in outpatient substance treatment. The patient was considered at risk for severe withdrawal, medical issues, overdose, and was unable to maintain abstinence. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient substance rehabilitation/detoxification treatment. 

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 the inpatient hospital admission at an inpatient rehabilitation level of care is substantiated.