Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Substance abuse inpatient rehabilitation

The insurer denied coverage for substance abuse inpatient rehabilitation.
 
The denial is overturned.

This patient reportedly was admitted to this inpatient substance/alcohol rehabilitation treatment setting. He reportedly was drinking alcohol daily and smoking multiple blunts of cannabis daily. He reportedly had trouble preparing meals, paying bills, and had difficulty with transportation when using, which was daily. He reportedly had mood swings and anger issues. 

The medical records provided enough specific evidence to support that he required this level of care then. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but 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. Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. In this case, this patient was considered in need of 24-hour substance residential rehabilitation treatment as he needed time in this 24-hour inpatient therapeutic structured and supervised setting to learn better coping skills, relapse prevention skills, improve insight into his addiction, better identify relapse triggers, improve motivation, and increase sober supports. 

In this case, this patient could not stop alcohol and cannabis use and it interfered with his functioning including his ability to maintain employment, prepare meals, pay bills, and for transportation. He also had anger issues and mood swings and was discharged from this setting after making threatening statements to staff and peers. Without the structure and supervision of this therapeutic inpatient substance residential treatment, he likely would have quickly relapsed, and he required a time in this 24-hour therapeutic supervised and structured rehabilitation treatment setting. While in this setting, he was not able to use substances as it was a 24 hour rehabilitation treatment and he did not have access to drugs or alcohol while in this treatment setting which allowed him to work on trying to improve his coping skills to enhance his chances of abstinence when discharged into the community, better identify triggers, improve insight, develop a relapse prevention plan, and improve sober supports. This inpatient rehabilitation treatment had activities that were structured daily to improve cognitive and behavioral patterns and to improve functioning to allow for development of skills to manage chronic patterns of substance/alcohol use and develop skills to cope with emotions and stress without return to substance/alcohol use. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance/alcohol rehabilitation treatment. It did not appear that the health care plan acted reasonably or in the best interests of the individual then.

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