Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Continued Residential Substance Abuse Treatment with Inpatient Behavioral Stay

The insurer denied the Continued Residential Substance Abuse Treatment with Inpatient Behavioral Stay. The denial was reversed.

This is a male patient with a history of multiple substance treatments that included inpatient treatment. He presented to a residential rehabilitation facility for substance rehabilitation treatment. His presenting symptoms included poor eating and sleeping, decreased energy, depressive, and anxiety. It was reported that his daily drug use included crack/cocaine, ecstasy, cannabis, and alcohol. While in treatment he attended multiple daily group therapy sessions and attended weekly individual therapy treatment. The patient was discharged from treatment due to noncompliance with the program rules and drug use. 

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 continued to use substances despite multiple negative consequences to use including incarceration, loss of multiple employments, changing residences, and relational strains. 

According to the LOCADTR he met criteria for inpatient substance residential rehabilitation treatment as he continued to use multiple substances despite multiple past inpatient substance treatments including recent inpatient substance treatments. Also, despite negative consequences of substance use including incarceration, loss of multiple employments, changing residences, and relational strains, he could not stop using multiple substances without the 24 hour therapeutic supervised and structured programming of this therapeutic residential treatment setting. It was reported that he continued to have cravings, urges to use substances, intrusive thoughts, impulses to stop treatment, fears of relapsing, and he needed more time in this sober and therapeutic setting to learn better coping and relapse prevention skills, improve insight into use, better deal with triggers and improve identifying them. He needed to better identify emotions and how it contributed to substance use. 

The National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that research indicates that most addicted individuals needs at least 3 months in treatment to significantly reduce or stop their drug use and 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. He reportedly had cravings and urges and eventually used crack/cocaine during his stay, and he had multiple past and recent inpatient rehabilitation treatments, and he still was unable to stop multiple substances of use. Without this structured and supervised therapeutic residential treatment, he likely would have relapsed sooner and been at risk for another overdose so he needed a significant amount of time in this treatment setting to give him the best chance of abstinence. 
It did not appear that the health care plan acted reasonably or in the best interests of the patient.

Based on the above, the medical necessity for continued Residential Substance Abuse Treatment with Inpatient Behavioral Stay is substantiated.  The insurer's denial is reversed.