Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient rehabilitation
The insurer denied coverage for Inpatient Rehabilitation.
The denial is overturned.
 
This adult was admitted to this inpatient substance rehabilitation treatment. She reportedly had relapsed with alcohol and was snorting 1 gram of cocaine daily, taking Percocet 20 milligrams (mg) twice per day, Xanax 1 mg 3-6 times per week, and needed abstinence in order to get spinal surgery. She reportedly had spinal injury including herniated discs and vertebrae, and also hypertension. She had a past inpatient substance rehabilitation treatment. She was divorced and unemployed and was a nurse. She had depression and anxiety also. It was reported that her mother's death triggered using cocaine, Percocet, and Xanax. She attended group therapy and was discharged.
  
The insurer denied coverage for inpatient substance rehabilitation treatment as not medically necessary treatment. They stated that she did not have co-occurring psychiatric or medical conditions requiring 24-hour inpatient substance rehabilitation treatment, did not have social, emotional, or developmental barriers to participate in treatment outside of inpatient level of care. They also stated that she was not at risk of life-threatening withdrawals. They recommended a less restrictive level of care then.

The medical records provided enough specific evidence to support that she required this inpatient therapeutic supervised and structured level of care. 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. In this case this patient was considered in need of 24-hour substance rehabilitation treatment as she was using multiple serious substances of use in large amounts daily and also used alcohol which put her at risk of medical consequences of use, overdose, and withdrawal symptoms. Her substance and alcohol use also interfered with her functioning occupationally and interpersonally resulting in unemployment and a divorce. She also needed abstinence in order to get the necessary spinal surgery. She lacked the coping skills and ability to identify relapse triggers to stop use. She also had comorbid pain due to her spinal issues and anxiety and depression as well as stressors including the death of her mother which contributed and triggered her use. 

According to the LOCADTR (Level of Care Determination) she met criteria for inpatient substance rehabilitation treatment as she continued to use large amounts of serious substances of use daily despite negative consequences and also despite a past inpatient substance rehabilitation treatment. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the substance abuse inpatient rehabilitation admission is substantiated.