Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Rehabilitation Services

The insurer denied inpatient rehabilitation services. The denial was reversed.   

This is a male patient with a history of bipolar disorder, multiple suicide attempts, and daily use of alcohol, heroin, marijuana and cocaine. It was reported that the patient has had multiple past inpatient detoxification treatments. He presented to a facility for substance abuse rehabilitation after completing a 24 hour inpatient detoxification treatment.  The patient's initial Clinical Opiate Withdrawal Scale (COWS) score was 19, and the patient's initial Clinical Institute Withdrawal Assessment (CIWA) score was 20. He was consulted by psychiatry and was treated with Librium, Olanzapine and Sertraline. 

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 inpatient substance rehabilitation treatment because the patient's history of high volume, polysubstance use put the patient at a significant risk for relapse upon discharge. The patient was homeless, and his recent psychiatric history was concerning for substance overdose and suicide. 

According to the LOCADTR criteria, this patient met criteria for inpatient substance rehabilitation treatment because the patient continued to use large amounts of heroin, alcohol and cocaine daily despite multiple past inpatient substance detoxification treatments. Also, for inpatient substance rehabilitation treatment, this patient met criteria because the patient was not likely to comply with treatment outside of a 24-hour structured treatment setting. The patient had comorbid mental health and medical conditions, and had social and emotional barriers to participate in treatment outside this inpatient setting. The patient was homeless and lacked support. The patient had multiple suicide attempts including. For the patient's comorbid, bipolar disorder, the patient was started on three psychotropic medications (Lithium, Olanzapine, and Sertraline). 

According to LOCADTR for substance residential treatment, one needs to be stable enough to manage emotional status, cravings, co-occuring psychiatric and medical conditions in a residential treatment setting. This patient was considered a high risk patient psychiatrically and medically due to his large amount of multiple and serious substance use and serious comorbid psychiatric symptoms which required treatment with multiple psychotropic medications. The patient also had past seizures, and tendency to resist treatment. It was in the patient's best interest to continue patient's rehabilitation treatment after completing inpatient substance detoxification at an inpatient setting to ensure patient safety and decrease the risk for relapse. The patient required more time in this inpatient treatment setting but had left against medical advice (AMA). The patient continued to use recreational drugs despite negative consequences due to his substance use, and lacked sober supports to help him maintain abstinence outside of a 24-hour, inpatient substance rehabilitation setting. The patient lacked coping skills, and needed to better identify relapse triggers and resist the triggers. Without this structured and supervised therapeutic rehabilitation treatment setting, the patient was at high risk for a rapid relapse and self-harm. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The carrier denial of coverage for the inpatient rehabilitation services is reversed. The medical necessity is substantiated.