Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder. 
Treatment: Inpatient substance residential treatment. 

The insurer denied coverage for inpatient substance residential treatment. 

The denial is overturned. 

This male patient has a history of  substance use disorder (SUD).  Per the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Summary of Recommendations, continued stay at the rehabilitation/residential level of care was requested.  The patient was experiencing urges and/or cravings, and had difficulty in relationships with peers or staff.  The patient was not ready to step down.  The patient prematurely split, which resulted in a new admission back to the facility as a relapse. 

He was admitted for inpatient substance residential treatment due to substance rehabilitation needs. The patient was using methamphetamine consistently for 3 years.  The patient had mood swings and symptoms and emotional symptoms triggering use.  The patient reportedly was the victim of sexual abuse at age 8 and it was reported that sex triggered use.  The patient had multiple jobs.  The patient did not have a supportive family and that it was a toxic family.  The patient had student loan debt.  During his inpatient stay, the patient attended group therapy and meditation and took Wellbutrin, Lithium, and Adderall. The patient was discharged and relapsed shortly after and was readmitted to this facility. 

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 continued 24-hour residential treatment then as he needed more time in this 24-hour inpatient therapeutic structured and supervised setting to learn more coping skills, relapse prevention skills, improve insight, better identify triggers, improve motivation, improve relapse prevention skills and sober supports. 

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 methamphetamine despite negative consequences of substance use including difficulties interpersonally and multiple employments, and high risk behaviors such as sexual activity which he reported was a trigger to use.  The patient could not stop using methamphetamine without the 24-hour therapeutic supervised and structured programming of this therapeutic residential treatment setting.  It was reported that the patient was not ready to step down yet and needed to work on better identifying triggers to substance use, improve insight, better control impulses, improve coping skills, and improve sober supports.  It is reported that the patient was internalizing feelings, did not think he could remain sober outside of this 24-hour therapeutic residential setting, was using drugs to cope with challenging emotions, needed better strategies to cope with mood swings and triggers, and he was not ready for discharge. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.