Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
	
Treatment: Continued Residential Substance Use Treatment Services

The insurer denied the continued residential substance use treatment services.

The denial was overturned.

This is a male patient who was admitted to inpatient substance residential treatment who reportedly eloped and relapsed with alcohol use and a nicotine vaporizer. The patient's diagnoses included Severe Cocaine Use Disorder, Opiate Use Disorder, Severe Hallucinogen Use Disorder, Inhalant Use Disorder, Amphetamine Use Disorder, Alcohol Use Disorder, Cannabis Use Disorder, Major Depressive Disorder and Attention Deficit Hyperactivity Disorder (ADHD). In early 2019 the patient reported having had multiple attempts of drug overdoses. His mood symptoms included depression, hopelessness and helplessness. His history also included of homicidal threats, self-injurious behavior that included cutting self, running away, property destruction, and multiple school suspensions. The patient reportedly eloped with the intent of stealing medications and overdosing. The patient was brought to the psychiatric hospital.
 
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. This patient was considered in need of a 24-hour residential treatment because of his history of relapsing immediately after receiving 24-hour inpatient substance residential treatment in the past and was even relapsing during this current stay in this substance residential treatment as he reportedly eloped twice to use alcohol and substances. The patient was also a high-risk patient as he was using multiple, serious substances of use and had a few instances of serious overdoses recently in early 2019. The patient had suicidal plans and intent, and could not stop substance use without being in at least a 24-hour inpatient substance residential treatment setting. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance residential rehabilitation treatment as he continued to use multiple serious substances of use despite past inpatient substance treatments and despite negative consequences of substance use including violence, self-injurious behavior, overdoses, homelessness, property destruction, homicidal threats, running away, and more severe depression. The patient could not stop using multiple substances without the 24-hour therapeutic supervised and structured programming of this therapeutic residential treatment setting; the patient even eloped a few times to use alcohol and substances. The patient was a significant risk of danger to self and others, and required at least this 24-hour therapeutic inpatient substance residential 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 continued Residential Substance Use Treatment services is substantiated.  The insurer's denial should be overturned.