Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.

Treatment: Inpatient substance abuse services.

The insurer denied coverage for inpatient substance abuse services.

The denial is overturned.

This patient reportedly was admitted to this inpatient substance rehabilitation treatment for substance rehabilitation treatment. It was reported that he could not maintain abstinence from substances and had limited coping skills and ability to identify relapse triggers. 
    
The reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment as 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 treatment then 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. 

According to the LOCADTR (level of care determination) he met criteria for inpatient substance residential rehabilitation treatment and could not maintain abstinence despite past reported substance treatment attempts. He reportedly was putting himself at risk medically including for overdose or medical complications due to methamphetamine use. Without the structure and supervision of this therapeutic inpatient substance residential treatment, he likely would have quickly relapsed if discharged during the denial period, and he required a substantial 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 while in this treatment setting which allowed him to work on improving his coping skills to enhance his chances of abstinence when discharged into the community. The 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. In this case this patient required a substantial amount of time in a 24-hour inpatient therapeutic residential treatment setting and he left AMA (against medical advice). 

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 Medically Supervised Inpatient Detoxification admission is overturned. Medical Necessity is substantiated.