Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cocaine Use Disorder
Treatment: Inpatient Rehabilitation Admission
The insurer denied: Inpatient Rehabilitation Admission
The denial is overturned.

The patient is an adult male. He was admitted to inpatient level substance use disorder rehabilitation services. His presentation for substance-related treatment was prompted by a decline in functioning and in the context of escalating use cocaine together with co-occurring psychiatric disorders, depression and anxiety.
The patient had no acute medical issues. However, 2 years ago the patient had a stroke related to the heavy cocaine use with residual hemiplegia. The patient's mental status examination included a disheveled and cooperative male with clear speech and thoughts that were organized, and goal directed. There were concentration difficulties. He reported low energy and sleep disturbance. Insight was limited and judgment impaired, and he had poor control of impulses. The treatment provided structure, monitoring, and the intensity of inpatient level services, which included intensive rehabilitation services with sober supports and monitoring for abstinence. Treatment included group, individual, and educational services with emphasis on coping skills, and 
with the goal of the development of a relapse prevention plan. The patient received psychotropic medications included mirtazapine and prn (as needed) use of Vistaril, as well as nicotine replacement. There was the opportunity to participate in 12-step recovery groups with assignments, and he worked with peers to address relapse issues and identification of triggers to use cocaine. The patient struggled with PAWS (post-acute-withdrawal syndrome) that diminished with persistent craving, and sleep disturbance, as noted, with prn (as needed) medications. During his brief inpatient stay, the patient continued to display co-occurring symptoms of the mood disorder and the lack of coping skills. Thus, the patient focused on the development of better coping skills, and participated in mindfulness training, and continued working on a relapse prevention plan. By the day of discharge, arrangements were completed with discharge and step down to lower-level care in the community with continued substance use disorder and psychiatric services, and encouragement to participate in recovery groups with the obtainment of a sponsor.

The Inpatient Rehabilitation Admission was medically necessary.

The inpatient rehabilitation services were medically necessary in order to address issues related to relapse with focus on a relapse prevention plan and additional work on developing coping skills in a case that poses high risk for relapse; in order to address co-morbid psychiatric disorders with medication adjustments; in order to address the patient's lack of awareness of the seriousness of his illness with psycho-education and evidence-based psychosocial interventions; in order to address the social environment including development of a safe and clinically appropriate discharge plan and disposition; and in order to work on coping skills that will be necessary in building an effective sober support system and continued recovery efforts with community providers while maintaining his abstinence with peer supported recovery groups. None of this therapeutic work could have been safely or effectively provided at a lower level of care in view of the multiple, complicating factors in this case, the high risk for relapse, the treatment history with relapses and continued use of substances despite access to treatment, and the lack of a reasonable recovery environment that includes high risk behaviors, and the patient's initial ambivalence towards treatment or lack of commitment to a recovery process.
This answer is consistent with prevailing standards of professional practice and ASAM (American Society of Addiction Medicine) Criteria and scientific literature and published practice guidelines.