Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.
Treatment: admission to the substance abuse inpatient rehabilitation level of care.
The insurer denied coverage for admission to the substance abuse inpatient rehabilitation level of care.
The denial is overturned.

This adult male was admitted to this inpatient substance rehabilitation treatment for alcohol and substance rehabilitation treatment. He reported that he could not be managed in an outpatient setting. It was reported that he was unable to remain abstinent, lacked coping skills and ability to identify relapse triggers. The patient had a past history of inpatient long term rehabilitation treatment and still was unable to remain abstinent. He reportedly was drinking 4 nips of liquor and two 24-hour ounce beers per day, smoking $100 of crack/cocaine per day, and smoking $20 of cannabis per day. He was unemployed and not married though he had a child. He also was anxious and had a history of bipolar disorder. He attended groups and individual therapy, and the plan was to complete this inpatient substance rehabilitation treatment and then attend long term inpatient substance residential treatment after that. The patient left against medical advice (AMA) prior to completing this inpatient 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. 
In this case this patient was considered in need of 24-hour substance rehabilitation treatment as he reportedly was using large amounts of alcohol daily and using serious substances daily including $100 of crack/cocaine in addition to cannabis daily which put him at risk of medical issues due to alcohol and cocaine use and also severe, complicated, and life-threatening withdrawals. He lacked the coping skills and ability to identify relapse triggers to stop use. 

According to the Level of Care for Alcohol & Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of alcohol, crack/cocaine, and cannabis daily despite a past long term 100-day inpatient substance treatment. He reportedly still was unable to remain abstinence after that treatment and stated that he could not be managed in an outpatient setting. He also reportedly lacked sober supports and stable housing to maintain abstinence outside of this 24-hour substance rehabilitation treatment, so he was considered at high risk to continue use if not in a 24-hour therapeutic substance rehabilitation treatment. He reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. He was unable to stop substance/alcohol use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. Without this structured and supervised therapeutic rehabilitation treatment he likely would have relapsed quickly. He also had a history of bipolar disorder as well which further increased his risk of relapse. He had a large amount of daily alcohol use and a large amount of daily significant crack/cocaine use putting at risk medically and also for withdrawal. The plan was for him to complete this inpatient substance rehabilitation treatment to learn better coping skills for sobriety and to better identify relapse triggers, but he left AMA. 

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

The insurer's denial of coverage for an admission to the substance abuse inpatient rehabilitation level of care is overturned. Medical Necessity is substantiated