Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse 
Treatment: Inpatient rehabilitation
The insurer is denied coverage for inpatient rehabilitation. 
The denial is overturned. 
This is a male patient who was admitted to inpatient substance rehabilitation treatment for alcohol and substance rehabilitation treatment. The patient reportedly completed a detoxification treatment in the hospital prior to this and it was recommended that he have this treatment. The patient reported drinking 3 pints of liquor per day, smoking 8-9 joints per day, and using an unknown amount of benzodiazepines daily. The patient reported having an arm surgery 1 month prior to admission and was given pain pills. The patient was homeless, unable to remain abstinent, lacked coping skills for sobriety, and needed to better identify relapse triggers. The patient reportedly was discharged to substance residential treatment for continued inpatient substance/alcohol 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), the patient met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol daily and cannabis as well as unknown amount of benzodiazepines daily. The patient reported drinking 3 pints of liquor per day and smoking 8-9 joints per day. In this case, this patient was considered in need of 24-hour substance rehabilitation treatment as he could not stop using multiple substances and alcohol, and lacked supports as he was homeless. The patient reportedly was unable to remain abstinent, lacked coping skills for sobriety, and needed to better identify relapse triggers; the patient likely would not have been compliant with treatment and was a high risk for relapse if the patient was not placed in 24-hour substance rehabilitation after his 24-hour detoxification treatment. The patient lacked sober supports to maintain abstinence outside of this 24-hour substance rehabilitation treatment and was 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 drop out rates. This patient required even more than the few days in this inpatient substance rehabilitation treatment as he was discharged to further 24-hour substance treatment. The patient needed time in a 24-hour sober therapeutic substance treatment to try to improve coping skills as he 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, the patient likely would have relapsed quickly. Furthermore, the patient was discharged to another inpatient substance/alcohol treatment for further rehabilitation treatment.
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 inpatient rehabilitation is substantiated. The insurer's denial should be reversed.