Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cocaine and Alcohol Use Disorder
Treatment: Inpatient substance rehabilitation
The insurer denied coverage for: Inpatient substance rehabilitation
The denial is: Reversed
This patient was admitted to inpatient substance rehabilitation for alcohol/substance rehabilitation. The patient  was snorting 1 gram (gm) of cocaine 3-4 times per week and drinking 1 bottle of wine and up to 10 shots of tequila daily. The patient had diagnoses of Cocaine and Alcohol Use Disorder and was taking Adderall for Attention Deficit Hyperactivity Disorder (ADHD) and Xanax for anxiety with reports of depression. The toxicology was positive for cocaine, tetrahydrocannabinol (THC), amphetamine, and benzodiazepines. The patient had hypertension and had elevated heart rate up to 98. There were past inpatient detoxification and rehabilitation treatments. The patient attended group and individual therapy. The patient was discharged against medical advice (AMA).

The reviewer disagrees with the decision to deny coverage for inpatient substance rehabilitation treatment as the medical records provided support that the patient required this 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 inpatient substance/alcohol rehabilitation treatment as the patient lacked sufficient coping skills and relapse prevention skills, ability to identify triggers, and enough sober supports to remain abstinent in a less restrictive setting. The patient was at risk for severe withdrawal due to the large amount of daily alcohol and cocaine use and also was at risk for overdose or medical complications from cocaine and alcohol use. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient met criteria for inpatient substance rehabilitation treatment because drug/alcohol use put the patient at risk for more severe withdrawal, complicated or life threatening withdrawal such as delirium tremens. Also, the patient had comorbid psychiatric conditions including ADHD, anxiety, and depression as well as comorbid medical issues including hypertension (HTN). It was reported the patient could not maintain abstinence even after past inpatient substance/alcohol treatment and the patient tried to stop but couldn't without this 24 hour therapeutic treatment setting. The patient needed to develop healthy coping skills and relapse prevention skills, and the boyfriend used cocaine and drugs and was a bad influence, and also that the patient used with friends. The patient witnessed domestic violence. The patient continued to use cocaine and alcohol despite negative consequences at work and with family. Substance and alcohol use resulted in an inability to fulfill life's obligations, and that there were daily urges to use. It was reported that the patient required this intensive treatment for motivating strategies, activities, and processing that was only available in this 24 hour rehabilitation treatment setting. The patient left against medical advice (AMA). Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, the patient likely would have relapsed as evidenced by the inability to stop use, relapse after a past inpatient substance treatment, and due to the lack of coping skills and sober supports. 

Based on the above, the insurer's denial must be reversed. 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 inpatient admission is substantiated.