Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 

Treatment: 28 days of Inpatient Substance Use Rehabilitation. 

The insurer denied coverage for 28 days of Inpatient Substance Use Rehabilitation. 

The denial is overturned. 

This patient reportedly was admitted to this inpatient substance rehabilitation treatment on due to substance and alcohol rehabilitation treatment. The patient reportedly was using $80 per day of crack/cocaine, drinking 12 pint of liquor, taking 1 tablet of Alprazolam with recent use, and had positive toxicology results despite being in a methadone maintenance program and receiving 90 milligrams (mg) of Methadone per day. The patient reportedly had a past inpatient rehabilitation treatment for 6 days and still could not maintain abstinence. The patient reportedly had a family history of substance use. The patient reportedly lacked coping skills for sobriety and had no prolonged abstinence reported. 

The insurer denied coverage for inpatient substance rehabilitation treatment as not medically necessary treatment then. They stated that there were no medical or mental health concerns requiring 24 hour inpatient treatment then. They recommended a less restrictive level of treatment then. 

The reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment as the medical records provided enough specific evidence to support that the patient required this level of care then. 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 supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24 hour substance rehabilitation as they reportedly were using large amounts of serious substances daily including $80 per day of crack/cocaine and a pint of liquor daily as well as 1 tablet of Alprazolam which put them at risk of medical consequences to crack/cocaine use with alcohol and a benzodiazepine and also at risk for overdose and withdrawal. The patient reportedly lacked the coping skills and ability to identify relapse triggers to stop use. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as they continued to use large amounts of crack/cocaine, alcohol, and benzodiazepine despite past inpatient substance rehabilitation treatments and despite being in a methadone maintenance program and receiving 90 mg of Methadone. The patient reportedly had positive toxicology results and could not maintain abstinence. The patient reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. The patient 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 the patient likely would have relapsed quickly again as evidenced by inability for abstinence after a past inpatient substance rehabilitation treatment a few months prior to this treatment. 

Based on the above, the insurer's denial must be reversed. 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 28 days of Inpatient Substance Use Rehabilitation is substantiated.