Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient substance rehabilitation treatment
The insurer denied coverage for: Inpatient substance rehabilitation treatment.
The denial is: Overturned.

This is an adult who was admitted to this inpatient substance rehabilitation treatment. The patient was reported to have been using 34 gram of methamphetamine daily. The patient reportedly had a history of opiate use for 14 years and was on medication assisted treatment (MAT) and taking Suboxone. The patient had a past Driving While Ability Impaired (DWAI) and was using substances despite negative consequences. The patient reportedly lacked enough coping skills for abstinence outside of a 24 hour inpatient treatment facility. The patient had comorbid psychiatric issues including past suicidal plans and attempts and diagnoses of bipolar disorder, attention deficit hyperactivity disorder (ADHD), and generalized anxiety disorder. The patient was taking psychotropic medications including Quetiapine, Aripiprazole, Venlafaxine, and Trazodone. It was reported that the patient's partner also was actively using methamphetamine. The patient was staying with their father and was employed. The patient attended group therapy and individual therapy and was discharged 3 weeks later with referral to outpatient substance treatment and self-help groups. 
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 treatment as the patient lacked sufficient coping skills and relapse prevention skills, ability to identify triggers, and enough sober supports to remain abstinent in a less restrictive setting. The patient reportedly was at risk for medical consequences to substance use and overdose as well as negative consequences to use and worsened psychiatric symptoms due to their comorbid significant psychiatric history. 
According to the Level of Care Determination (LOCADTR) the patient met criteria for inpatient substance rehabilitation treatment as they were using methamphetamine daily in large amounts which put the patient at risk for withdrawal or overdose and the patient reportedly could not maintain abstinence outside of a 24 hour therapeutic substance rehabilitation treatment. The patient was considered a high risk psychiatrically also due to their past suicidal plan and attempt and comorbid bipolar disorder, attention deficit hyperactivity disorder (ADHD), and anxiety. The patient was in medication assisted treatment (MAT) due to significant past opiate use and was taking Suboxone and had past Driving While Ability Impaired (DWAI) due to use which put the patient and others at risk of danger. The patient was using daily substances in hazardous situations despite past negative consequences to use and was using in frequencies that were considered to be risk for medical and worsened mental health conditions. Also, the patient had comorbid bipolar disorder with a reported history of past suicide attempt and plan involving a gun so the patient was considered at higher risk for suicide due to this and using substances could increase their risk of suicide. 
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 substance abuse inpatient rehabilitation is substantiated.