Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heroin and crack use

Treatment: 2 units of inpatient substance use rehabilitation treatment, revenue code 0128

The insurer denied coverage for 2 units of inpatient substance use rehabilitation treatment, revenue code 0128.

The denial is overturned.

This patient was admitted to this inpatient substance residential rehabilitation treatment due to heroin and crack use. He reportedly was injecting 20 bags of heroin daily and had extensive drug use history. He reportedly also was smoking 1 gram of crack per day with years of use. He reportedly had a past inpatient substance residential rehabilitation treatment. He reportedly was in a Program Treatment. He reportedly had anxiety. He reportedly complained of feeling sick and not getting enough Methadone, so he left against medical advice (AMA) after receiving a dose of 50 mg (milligram) of Methadone.
  
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 residential treatment then as he needed time in this 24 hour inpatient therapeutic structured and supervised setting to learn coping skills, relapse prevention skills, improve insight, better identify triggers, improve motivation, and increase sober supports. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance residential rehabilitation treatment as he continued to use large amounts of heroin intravenous (IV) daily including up to 20 bags per day and also 1 gram of crack per day by smoking despite past inpatient substance residential rehabilitation treatment and despite putting himself at risk medically including for overdose and severe withdrawal.  

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 treatment time in a 24 hour inpatient therapeutic residential treatment setting. He reported that he felt like he was dying and stated that he thought that he was not receiving enough Methadone as he reported that he was taking 120 mg per day. He reportedly received 50 mg of Methadone and then left against medical advice (AMA). This was a high-risk patient who could not stop heroin or crack use and needed at least the entire time in this sober therapeutic 24 hour residential rehabilitation treatment in order to develop relapse prevention skills, strengthen coping skills, decrease impulsivity, better identify triggers, improve insight, and increase sober supports. Without this structured and supervised therapeutic residential treatment, he likely would have relapsed immediately as he reportedly still reported withdrawal and requested higher doses of Methadone than what was being given to him in the residential treatment. 

It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the individual then.

The insurer's denial of coverage for 2 units of inpatient substance use rehabilitation treatment, revenue code 0128, is overturned. Medical necessity is substantiated.