Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder
Treatment: Substance abuse inpatient rehabilitation
The insurer denied coverage for Substance abuse inpatient rehabilitation.
The denial is: Overturned

This is an adult who was admitted to the inpatient substance rehabilitation treatment center. The patient reportedly was using $100 crack/cocaine 3 - 6 times per week and also smoking cannabis a few times per month. The patient reportedly started use at age 20 for crack/cocaine and at age 16 for cannabis. The patient had past inpatient substance detoxification treatment twice but could not maintain abstinence. The patient lacked coping skills and a support system for abstinence. The patient reportedly lived in a shelter. The patient also had asthma. The patient reportedly attended group and individual therapy. The patient reportedly chose not to follow up with medication-assisted treatment (MAT). 

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. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met the criteria for inpatient substance rehabilitation treatment as they continued to use large amounts of cocaine 3 - 6 times per week including up to $100 with a long history of use (40 years) and could not maintain any abstinence despite past inpatient treatments. The patient reportedly continued to use large amounts of crack/cocaine putting him at high risk for medical consequences including cardiac arrest or stroke. The patient had a positive toxicology for cocaine and tetrahydrocannabinol (THC). The patient reportedly lacked coping skills and support. It was not likely that the patient could safely and effectively be treated in a less restrictive setting as the patient would have been exposed to cocaine and lacked the skills to try to rehabilitate while not in a 24-hour setting. It was reported that other residents in the shelter where the patient lived were active substance users, which increased the patient's ability to obtain substances. It was not likely that the patient could maintain abstinence if not in a 24-hour therapeutic supervised and structured inpatient substance rehabilitation treatment setting. 

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

In this case, the patient required at least this time in the inpatient substance rehabilitation treatment setting to work in group and individual therapy to try to improve coping skills, insight into use, decision-making, better identifying relapse triggers, obtaining relapse prevention skills, and increasing sober support. Without this structured and supervised therapeutic rehabilitation treatment, the patient likely would have relapsed quickly again and been more at risk medically for medical complications due to the large amount of cocaine use and long history of use. 

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 substance abuse inpatient rehabilitation is substantiated.