Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This adult male patient was admitted to inpatient substance rehabilitation treatment due to daily use of synthetic cannabinoid (K2). He was using 2-4 joints per day. He reportedly was in intensive outpatient program (IOP) substance treatment and still could not stop substance use. He also continued to use this substance despite negative consequences including past legal problems including for robbery, medical consequences due to substance use including liver damage and a diagnosis of hepatitis C, and he reportedly lacked coping skills and relapse prevention skills for abstinence. He also was homeless and was living with friends for the past few months, so he lacked supports. The patient also had a medical history of hypertension, gastroesophageal reflux disease (GERD), glaucoma, left knee replacement, in addition to liver damage and hepatitis C. He attended group and individual therapy and had cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), and rational emotive behavioral therapy (REBT), as well as medication adjustments. The patient was discharged with a referral back to IOP.
    
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but 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. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. 

In this case this patient was considered in need of 24-hour residential treatment as he needed time in this 24-hour inpatient therapeutic structured and supervised setting to learn coping skills, relapse prevention skills, improve insight, better identify triggers, improve motivation, improve relapse prevention skills and build sober supports. 

The Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that research indicates that the best treatment outcomes occur with longer durations of treatment and states that recovery from drug addiction is a long-term process. It also states that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. 

In this case, the patient required the treatment time in this residential treatment setting. He needed the entire time in this sober therapeutic 24-hour residential rehabilitation treatment in order to develop relapse prevention skills, strengthen coping skills, decrease impulsivity, better identify triggers, improve relapse prevention skills and insight, and sober supports. He also reportedly had psychiatric issues including depression, anxiety, panic attacks, and sleeping problems, as well as medical issues including liver damage and hepatitis C due to substance use. He reportedly was homeless and had limited sober supports. Without this structured and supervised therapeutic residential treatment, he likely would have been unable to maintain abstinence, so he required this 24-hour therapeutic inpatient substance residential treatment. 

This reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment as the medical records provided enough specific evidence to support that he required this level of care. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the individual.

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.