Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse.
Treatment:  Inpatient rehabilitation admission.
 
The insurer denied the inpatient rehabilitation admission.  The denial was overturned.

This is a male patient who was admitted for inpatient substance rehabilitation treatment.  The patient reportedly had withdrawal symptoms that included tremors, diarrhea, elevated heart rate of 98, dizziness, insomnia, sleeping problems, and was drinking 12 pint of vodka per day and smoking 2-3 blunts of cannabis per day.  The patient had past history of psychiatric hospitalizations for depression and anxiety and inpatient substance rehabilitation treatment.  The patient reportedly left against medical advice (AMA) in the past.  The patient was currently homeless and lacked coping skills for abstinence.  During inpatient stay, the patient was treated with Lexapro, Lamictal, and Prazosin.  The patient was treated and was then discharged to the a residential housing facility for further alcohol/substance rehabilitation treatment.

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. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation.  The patient was using 2-3 blunts of cannabis, smoking 8-9 joints, and drinking 3 pints of liquor daily despite multiple past inpatient rehabilitation treatments.  In this case, this patient was considered in need of 24-hour substance rehabilitation treatment, as he also had reports of withdrawal symptoms including tremors, diarrhea, elevated heart rate of 98, dizziness, insomnia, sleeping problems and was at risk of severe, complicated, and life threatening withdrawal.  The patient was homeless and lacked sober support.  The patient's past history of leaving treatment against medical advice indicate that this patient would not have been complaint with treatment at a less restrictive level of care than inpatient substance rehabilitation.  The patient was at a high risk for relapse.  The patient also had comorbid psychiatric issues including depression and had past psychiatric hospitalizations and also was taking medication for depression.  

According to the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide, the best treatment outcomes occur with longer durations of treatment.  It also states that recovery from drug addiction is a long term process and that treatment techniques to increase motivation for treatment are necessary to prevent drop out rates.  In this case, this patient required even more than the days in this inpatient substance rehabilitation treatment, as he was discharged to further 24-hour substance treatment in an inpatient substance residential treatment for further alcohol/substance rehabilitation treatment.  Without this structured and supervised therapeutic rehabilitation treatment, the patient likely would have relapsed quickly and been more at risk for worsened withdrawal symptoms and worsened psychiatric symptoms. 

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 the inpatient rehabilitation admission is overturned.