Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse.
Treatment:  5 units of Inpatient Substance Use Rehabilitation Treatment.

The insurer denied coverage for 5 units of Inpatient Substance Use Rehabilitation Treatment.  The denial is reversed. 

This was a male who was admitted to inpatient substance rehabilitation treatment after being stepped down from an inpatient substance detoxification treatment.  The patient reportedly had a history of drinking 2-3 bottles of brandy per day and crack/cocaine use.  It was reported that the patient had been incarcerated for substance use.  The patient lacked coping skills and was unable to identify triggers.  The patient lived in a shelter in which there was easy access to substance use.  The patient reported that both of his parents were alcoholics.  His inpatient treatment included Zoloft, Propanolol, and attendance in group sessions.  The patient was then transferred to another treatment facility for further inpatient substance rehabilitation 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.  In this case, the patient was considered in need of 24-hour substance rehabilitation treatment, as he reportedly was using large amounts of alcohol daily, which put him at risk of overdose and also severe, complicated, and life threatening withdrawals.  The patient 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 he continued to use large amounts of alcohol, despite negative consequences to use including legal problems, as he was in jail due to use.  The patient also lacked sober supports to maintain abstinence outside of this 24-hour substance rehabilitation treatment, as he was living in a homeless shelter where there was access to substances, and he lacked sober supports.  The patient reported that both of his parents were alcoholics, which put this patient at a high risk to continue use.  The patient lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills.  The patient was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting.  Without this structured and supervised therapeutic rehabilitation treatment setting, the patient likely would have relapsed quickly.  Furthermore, the patient was transferred to another rehabilitation facility for further inpatient substance rehabilitation treatment when a bed became available.  The inpatient rehabilitation treatment was medically necessary for this patient.

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

Based on the above, the medical necessity for the 5 units of Inpatient Substance Use
Rehabilitation Treatment, code 0128 is substantiated.  The insurer's denial should be reversed.