Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment inpatient substance abuse rehabilitation admission

The insurer denied coverage for inpatient substance abuse rehabilitation admission

The denial is overturned

This female that was admitted to inpatient substance rehabilitation for alcohol and substance rehabilitation treatment. She reportedly was drinking a fifth of alcohol per day, smoking 2 blunts of cannabis per day, and using cocaine. Her toxicology was positive for cocaine, benzodiazepines, and THC (tetrahydrocannabinol). The patient had multiple past inpatient substance detoxification treatments and rehabilitation treatments. She also had comorbid schizophrenia-bipolar diagnosis and past inpatient psychiatric hospitalizations. She reportedly had no clean time and lacked coping skills, ability to identify relapse triggers, insight into use and the consequences of use, lacked relapse prevention skills and sober support, and was homeless. She had 4 past arrests in 6 months. The patient attended group and individual therapy and took Zyprexa, Quetiapine, Trazodone, and Neurontin. She reportedly was supposed to be discharged to residential treatment but was combative and refused to go so she was discharged to a shelter.

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 she reportedly was using large amounts of alcohol daily and using serious substances daily including cocaine in addition to daily cannabis use and she could not maintain abstinence despite multiple inpatient substance detoxification and rehabilitation treatments. She reportedly lacked the coping skills and ability to identify relapse triggers to stop use and lacked sober supports and relapse prevention skills as she was homeless. She also had comorbid psychiatric conditions including a diagnosis of schizophrenia-bipolar and was noncompliant with psychotropic medications due to her substance use. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she met criteria for inpatient substance rehabilitation treatment as she continued to use large amounts of alcohol and cannabis and also was using cocaine despite multiple past inpatient substance detoxification and rehabilitation treatments. That was specific evidence that inpatient substance rehabilitation treatment was medically necessary treatment then. She needed to improve her coping and relapse prevention skills, identification of relapse triggers, insight into use and the consequences of use, and increase sober supports. She was unable to stop alcohol substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. Without this structured and supervised inpatient therapeutic rehabilitation treatment she likely would have relapsed very quickly. Also, she could not stop use for this therapeutic treatment without being in a 24-hour inpatient substance rehabilitation treatment. 

The medical records provided enough specific evidence to support that she required this level of care. 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 substance abuse rehabilitation admission is overturned. Medical necessity is substantiated.