Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol and Cocaine Use Disorder
Treatment: Inpatient rehabilitation treatment
The insurer denied coverage for inpatient rehabilitation treatment.
The denial is overturned.

The patient was admitted to this inpatient substance rehabilitation treatment for alcohol and substance rehabilitation treatment. He reportedly was drinking four 25-ounce beers daily with a 40-year history of alcohol use and smoking $500-$1000 per month of crack/cocaine. He reportedly had multiple past inpatient alcohol/substance detoxification and rehabilitation treatments and relapsed and could not maintain abstinence. He reportedly lacked coping skills and the ability to identify relapse triggers and used alcohol and substances to cope and deal with symptoms and stressors. He reportedly also had a diagnosis of bipolar disorder in addition to Alcohol and Cocaine Use Disorder. He reportedly had hepatitis B and hypertension. The goal was for completion of this treatment to set up Vivitrol treatment but he left AMA (against medical advice).
  
The medical records provided enough specific evidence to support that he required this level of care. 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 he reportedly was using large amounts of alcohol daily and using serious substances including crack/cocaine, which put him at risk medically and for severe, complicated, and life-threatening withdrawals. He lacked the coping skills and ability to identify relapse triggers to stop use. 

He reportedly had 12 inpatient substance detoxification treatments and 2 inpatient rehabilitation treatments and still relapsed and was unable to maintain abstinence. He reportedly had a recent inpatient detoxification treatment the month prior to this admission. He had a comorbid psychiatric diagnosis of bipolar disorder-depressed and was not compliant. He reportedly lacked positive peer support. The goal was for him to learn better coping skills, improve insight into use, better identify relapse triggers, and to learn how to better deal with drug cravings.  He reportedly stated that he could not maintain abstinence outside of a 24-hour inpatient therapeutic treatment setting.  He 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 he likely would have relapsed quickly as evidenced by relapsing after multiple past inpatient substance/alcohol treatments.
Based on the above, the insurer's denial must be overturned. 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 inpatient rehabilitation treatment services is substantiated.