Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse. 
Treatment: Inpatient substance rehabilitation. 	
The insurer denied coverage for inpatient substance rehabilitation.
The denial is overturned. 

This patient reportedly was admitted to this inpatient substance rehabilitation facility for substance rehabilitation treatment. He reportedly had a history of heroin use though he denied current use and was taking Methadone. He reportedly had multiple past inpatient substance treatments and did not complete 2 of them. He reportedly was homeless and lacked supports for maintained abstinence. He reportedly relapsed due to depression and a failed relationship. He reportedly had medical issues including neuropathy, and asthma. He reportedly lacked coping skills, relapse prevention skills, the ability to identify triggers, and lacked insight and motivation for abstinence. He reportedly left AMA (against medical advice). 
  
The insurer denied coverage for this inpatient substance rehabilitation treatment as not medically necessary treatment. They stated that he did not require 24-hour inpatient substance rehabilitation treatment based on LOCADTR (Level of Care Determination), and they recommended a less restrictive level of care then. 
  
The medical records provided enough specific evidence to support that he required this level of care then. The APA (American Psychiatric Association) 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 lacked sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he relapsed after multiple past inpatient substance treatments and was homeless and lacked supports and motivation, insight, and judgment to be treated outside of this 24-hour therapeutic inpatient substance rehabilitation treatment. He reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. He reportedly had 7 past relapses and could not maintain abstinence, so he required a 24-hour inpatient therapeutic supervised and structured inpatient substance rehabilitation treatment setting then. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed again as evidenced by relapses after past inpatient substance treatments. He lacked sober supports and was homeless so it was unlikely that he could have been safely and effectively treated in a less restrictive setting then.  As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance rehabilitation treatment. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the individual. 

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

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