Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cocaine Use Disorder, Cannabis Use Disorder, and Alcohol Use Disorder.

Treatment inpatient chemical dependency admission.

The insurer denied coverage for inpatient chemical dependency admission.

The denial is overturned.
	
This is a male admitted to this inpatient substance rehabilitation treatment due to crack/cocaine, cannabis, and alcohol use. It was reported that he was smoking $100 per day of crack/cocaine with last use the day of admission and first use at an early age. He reportedly was smoking 1 blunt of cannabis daily with first use at an early age and last use the day of admission. He had diagnoses of Cocaine Use Disorder, Cannabis Use Disorder, and Alcohol Use Disorder. He reportedly had twenty past substance treatments. He reportedly was drinking alcohol at an early age and was using Vivitrol IM (intramuscular) for treatment of alcohol use disorder. He lacked coping skills and relapse prevention skills, had difficulty identifying triggers, and was considered a high risk for relapse. He attended group and individual therapy. He was discharged.
  
The medical records provided enough specific evidence to support that the patient required inpatient 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 as he reportedly was using large amounts of crack/cocaine, cannabis., and alcohol daily and could not stop use despite 20 past inpatient substance treatments. He lacked the coping skills and ability to identify relapse triggers to stop use.   
 
According to the LOCADTR (Level of Care or Alcohol and Drug Treatment Referral), he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol, crack/cocaine, cannabis despite multiple past substance treatments and despite IM Vivitrol treatment. He lacked coping skills to maintain abstinence outside of this 24-hour substance rehabilitation treatment and needed to better identify relapse triggers and to learn relapse prevention skills. Notes reported that he needed to work on relapse prevention skills and better identification of triggers and stated that he would agree to follow up outpatient after this inpatient treatment. He also reported that he had multiple past substance/alcohol treatments and was unable to maintain abstinence. Notes reported that he was working on relapse trigger identification and improving insight. Notes reported that he was focusing on recovery skills. Notes reported that he was working on coping skills and relapse triggers. Notes reported that he was working on problem solving. Notes reported that he was working on motivation for change. Notes reported that he was trying to avoid triggers to improve his chances of abstinence in recovery. He could not stop multiple substances of use and alcohol 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 multiple relapses after multiple other substance/alcohol treatment settings. It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the individual.

The insurer's denial of coverage for the inpatient chemical dependency admission is overturned. Medical Necessity is substantiated.