Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse
Treatment:  Continued inpatient rehabilitation services

The insurer denied coverage for continued inpatient rehabilitation services.  The denial is reversed. 

This patient is a male was admitted to the inpatient substance rehabilitation treatment for substance rehabilitation treatment.  The patient was mandated  to complete a number of specified days of treatment.  The patient had been using hundreds of dollars' worth of crack per day with over two-decade history of use, and was drinking several packs of beer per day with over two-decade history of use.  The patient had multiple past substance treatments, including inpatient rehabilitation treatment and outpatient treatment, and still relapsed and could not maintain abstinence.  The patient's longest reported voluntary abstinence was several months.  The patient had a wound and chronic back pain.  The patient was also homeless. 

The patient was working on a relapse prevention plan, better identification of triggers, improving insight and coping skills.  The patient was discharged with a referral to substance Intensive Outpatient Program (IOP) for five days per week treatment.  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.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this case patient met criteria for inpatient substance rehabilitation treatment, as the patient continued to use large amounts of crack daily and alcohol, and also heroin at times and cannabis use.  This patient was considered in need of 24-hour substance rehabilitation treatment for the entire inpatient substance rehabilitation treatment stay, as the patient could not stop using multiple substances and alcohol despite negative consequences to use, including legal problems as he was on parole.  The patient was also at risk for medical consequences to his polysubstance use.  The patient continued to use despite past substance treatments including inpatient rehabilitation treatment and outpatient treatment and still relapsed and could not maintain abstinence.  This showed that the patient lacked sober supports to maintain abstinence outside of this 24-hour substance rehabilitation treatment, and the patient was also homeless.

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, this patient required more than just two weeks in this 24-hour residential treatment and required the full amount of time including until discharge, as he was at high risk for overdose, as he was using multiple serious substances.  The patient needed more time to try to improve coping skills, as he lacked coping skills, and needed to better identify relapse triggers and to learn relapse prevention skills.

The continued inpatient rehabilitation services were medically necessary to treat this patient's medical condition. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the continued inpatient rehabilitation services is reversed.  The medical necessity is substantiated.