Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment inpatient substance abuse admission

The insurer denied coverage for inpatient substance abuse admission

The denial is overturned

This patient reportedly was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation treatment. He reportedly was using $100 per day of crack cocaine by smoking it and using 3-4 bags of heroin per week, as well as drinking 6 or more beers per day. He reportedly had a past overdose. He reportedly had a positive toxicology for cocaine and Methadone. He reportedly was in a program. He reportedly had no abstinent time. He reportedly had multiple past substance treatments including 25 past inpatient substance detoxification treatments and 10 inpatient substance rehabilitation treatments, as well as outpatient treatment. He reportedly had past psychiatric hospitalizations for schizoaffective disorder-depressive type. He reportedly lacked coping skills, ability to identify relapse triggers, insight into use, and could not maintain any abstinence. He reportedly had a recent inpatient substance rehabilitation treatment and left AMA (against medical advice). He reportedly was discharged and was referred back to the program.
    
According to the LOCADTR (Level of Care for Alcohol and Drug Treatment Referral), he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of substances daily putting him at risk medically and for withdrawal despite past multiple treatments including 25 past inpatient substance detoxification treatments and 10 inpatient substance rehabilitation treatments, as well as outpatient treatment. He reportedly lacked coping skills, ability to identify relapse triggers, insight into use, and could not maintain any abstinence despite multiple inpatient substance treatments. He also reportedly had a past overdose so he was at risk medically for another overdose. It was reported that while he was in inpatient substance rehabilitation treatment, he tried to leave AMA in order to use substances and get intoxicated. It also was reported that he was extremely anxious. It was reported that his use of substances was interfering with his functioning and put him more at risk for worsened psychiatric symptoms. Also, the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that research indicates that 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 drop out rates. He required at least the time in this 24 hour inpatient substance rehabilitation treatment. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly as evidenced by relapses after multiple past inpatient substance treatments. It was not likely that he could maintain abstinence and safely and effectively be treated in a less restrictive level of care other than an inpatient substance rehabilitation treatment then. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance rehabilitation treatment. It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the individual then.

The insurer's denial of coverage for the inpatient substance abuse is overturned. Medical Necessity is substantiated.