Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cannabis Addiction

Treatment: Substance use inpatient rehabilitation level of care

The insurer denied coverage for substance use inpatient rehabilitation level of care

The denial is overturned.

This patient reportedly was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation treatment due to cannabis dependence. The patient reportedly was smoking 3-4 joints of cannabis daily and had a significant history and could not stop even at a lower level of care in the substance intensive outpatient program (IOP). The patient reportedly had positive toxicology screens for tetrahydrocannabinol (THC) despite being in substance IOP treatment. The patient also reportedly had a diagnosis of schizophrenia and was taking Haldol Decanoate intramuscular (IM) every 4 weeks and Clozapine and Depakote. The patient reportedly had a history of past psychiatric hospitalizations and past arrests for assault. The patient reportedly was unemployed and lacked coping skills and support to remain abstinent outside of this inpatient setting. The patient reportedly also was on assisted outpatient treatment (AOT) for psychiatric treatment. The patient reportedly attended individual and group therapy and was discharged and referred to their substance intensive outpatient program treatment and psychiatric mental health treatment. 
 
The reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment and the medical records provided did provide enough specific evidence to support that they required this level of care then. 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 and reportedly was using large amounts of cannabis up to 3-4 joints daily which put them at risk of worsened psychotic symptoms as they had a diagnosis of schizophrenia and had reports of auditory hallucinations and past psychiatric hospitalizations and was taking Haldol Decanoate IM every 4 weeks and also Clozapine and Depakote, and the patient was at risk of withdrawal and medical issues from cannabis intoxication. The patient reportedly lacked the coping skills and ability to identify relapse triggers to stop use. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as they continued to use large amounts of cannabis daily and was unable to stop use without a 24-hour substance free therapeutic treatment setting as they continued to use large amounts of cannabis despite being in substance IOP treatment. If the patient continued to use cannabis, it put them at higher risk of worsened psychotic symptoms, so the patient needed to be abstinent.  As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance rehabilitation treatment. 

Based on the above, the insurer's denial must be reversed. 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 the substance use inpatient rehabilitation level of is substantiated.