Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cocaine, cannabis, and alcohol use disorder

Treatment: Inpatient chemical dependency, rehabilitation admission

The insurer denied coverage for inpatient chemical dependency, rehabilitation admission.

The denial is overturned.

The patient is a male admitted to inpatient chemical dependency substance rehabilitation treatment. He reportedly was drinking 1 pint of rum and a 12-ounce beer several times per week and using 4 bags of crack/cocaine daily, and $40 of marijuana a few times per month. He reportedly had cocaine, cannabis, and alcohol use disorder. He had a positive toxicology for cocaine, tetrahydrocannabinol, and Methadone, and had a blood alcohol level of .056. He had a Clinical Opiate Withdrawal Score (COWS) of 11. He reportedly could not maintain abstinence and had no abstinent time despite 3 past inpatient rehabilitation treatments. He reportedly lacked coping skills and ability to identify relapse triggers. He reportedly lived at a shelter. He continued with post withdrawal and cravings. He attended individual and group therapy. He was discharged for continued inpatient substance treatment at a residential treatment for step down and continued treatment.
    
The American Psychological 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 reportedly was using large amounts of alcohol, crack/cocaine, and lacked the coping skills and ability to identify relapse triggers to stop use and reportedly could not maintain any abstinence at all. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of substances daily putting him at risk medically and for withdrawal despite multiple past inpatient substance rehabilitation treatments so it was not likely that a less restrictive level of care would be effective. It was reported that after his 28 days stay in this inpatient substance rehabilitation treatment setting, he was transitioned to the next least restrictive level of care, a substance residential treatment. Transitioning to the next least restrictive level of care is considered standard and appropriate treatment, which was the case with this patient. Also, the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide reports that research indicates that that the best treatment outcomes occur with longer durations of treatment and states that recovery from drug addiction is a long-term process. It also states that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. Without this structured and supervised therapeutic rehabilitation treatment, he likely would have relapsed quickly, as evidenced by relapses after multiple past inpatient substance rehabilitation treatments. It was not likely that he could maintain abstinence and safely and effectively be treated in a less restrictive level of care other than an inpatient substance rehabilitation treatment and he had medical risks if he were to continue using alcohol and cocaine. 

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

The insurer's denial of coverage for inpatient chemical dependency, rehabilitation admission is overturned. Medical necessity is substantiated.