Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient rehabilitation services
The insurer denied coverage for the inpatient rehabilitation services.
The denial is overturned.

This adult was admitted to this inpatient substance rehabilitation treatment as he had no reported abstinence and was drinking 1 pint of liquor and 8 beers per day, using $20 of intravenous (IV) cocaine and 13 bags of IV heroin 3-6 times per week. He reportedly had past overdoses and past suicidal ideation and comorbid psychiatric diagnosis of schizoaffective disorder-bipolar type but was noncompliant with medications. He reportedly had bilateral abscess and cellulitis. He reportedly was unemployed. The goal was for him to complete this inpatient substance rehabilitation treatment and then be transferred to a long term substance residential treatment but he reportedly left against medical advice (AMA). 

The chart notes provided enough specific evidence to support that he required this level of care. 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 as he lacked sufficient motivation and substance-free social supports to remain abstinent in an ambulatory setting as evidenced by the fact that he had no abstinence time reported. This patient was considered a high risk patient due to past overdoses and suicidal thinking and comorbid psychiatric diagnosis of schizoaffective disorder. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance rehabilitation treatment as he reportedly was using large amounts of alcohol daily including drinking 1 pint of liquor and 8 beers per day, using $20 of IV cocaine, and using large amounts of heroin including 13 bags of IV heroin 3-6 times per week. This put him at high risk medically for overdose and for other medical problems and he had medical issues including abscess and cellulitis. He reportedly had past overdoses which put him at risk for more. He also had comorbid psychiatric issues including past suicidal thinking and had schizoaffective disorder but was noncompliant with medication. He reportedly lacked the motivation, insight, coping skills, relapse prevention skills, and ability to identify relapse triggers, and lacked sober supports so he required this inpatient substance rehabilitation treatment, and then transition to a long term substance residential treatment. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, he likely would have relapsed immediately. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for inpatient rehabilitation services is substantiated.