Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Substance Residential Treatment
The insurer is denied coverage for inpatient substance residential treatment. 
The denial is overturned. 

This is a female patient who was admitted to this inpatient substance residential treatment. She had been using cannabis and inhalants to self-medicate her mood symptoms. She had depressed mood, hopelessness, isolation, anhedonia, sleeping and appetite problems, and had a history of self-injurious behavior, and suicidal thoughts. She was involved in dangerous behavior related to her substance use. She had past outpatient treatment and was still using cannabis and inhalants and still struggled with mental health issues. It was reported that her parents wanted the patient to go to residential treatment for help. She was discharged to a wilderness program.

The insurer denied coverage for this inpatient substance residential treatment as not medically necessary treatment. They stated that she did not meet criteria for high intensity managed residential treatment. They stated that she had no acute post withdrawal, was able to participate in the recovery plan, was not aggressive, had stable mood, and did not require 24-hour treatment. They recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for inpatient substance residential treatment as the chart notes did provide enough specific evidence to support the need for this residential treatment. 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. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), she met criteria for inpatient substance residential rehabilitation treatment. This was evidenced by the fact that she continued to use substances to medicate her mood and anxiety symptoms despite negative consequences of substance use and despite past multiple outpatient treatments, multiple past medication trials and Transcranial Magnetic Stimulation (TMS) therapy.

In this case, this patient was considered in need of 24-hour residential treatment as she had high risk and dangerous behavior related to her substance use. She was also caught sneaking out even while in this 24-hour residential setting; therefore, she required this level of care as she was a high risk for relapse without this supervised and structured setting. Notes reported continued emotional distress and that she was discouraged and overwhelmed. Notes reported that she yelled as an expression of her anger and was working on internal motivation. She required this 24-hour therapeutic inpatient substance residential treatment.

As a result, reverse the previous decision and approve coverage for inpatient substance residential treatment. The health care plan did not act reasonably, or with sound clinical judgment, or in the best interests of the patient.

The carrier's denial of coverage for the Substance Use Disorder Services at a Residential Treatment Level of Care is overturned. The medical necessity is substantiated.