Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use. 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient who was admitted to inpatient substance rehabilitation treatment in this hospital setting from inpatient substance detoxification treatment.  He had a history of alcohol, benzodiazepine, and cocaine use and a past alcohol withdrawal seizure, as well as multiple past inpatient substance treatments without sustained abstinence.  He also had a history of Bipolar Disorder and Attention Deficit Hyperactivity Disorder (ADHD) and anxiety.  He was taking Zoloft and Gabapentin.  He was in a Methadone treatment program.  He was the lone survivor in a motor vehicle accident and also was the victim of trauma.  He worked on improving coping skills, better identification of relapse triggers, relapse prevention skills, and improving insight into his addiction.  He was discharged with recommendations for further 24 hour inpatient substance rehabilitation treatment in a residential 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 lacked sufficient motivation and/or substance-free social supports to remain abstinent in a less restrictive setting.  He had a history of past withdrawal seizures which put him at high risk of life threatening withdrawal such as delirium tremens so inpatient hospital rehabilitation treatment was considered medically necessary treatment.  He lacked the skills necessary to maintain abstinence and was at risk for overdose due to benzodiazepine and alcohol use with cocaine.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he relapsed after past multiple inpatient substance detoxification and rehabilitation treatments.  He also had comorbid psychiatric disorder including bipolar disorder and ADHD.  He reportedly lacked sober supports, motivation, insight, and judgment to be treated outside of this 24 hour therapeutic inpatient substance rehabilitation treatment.  He lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills.  Without this structured and supervised therapeutic residential treatment he likely would have relapsed again as evidenced by relapses after past inpatient substance treatments.  He reportedly worked on improving coping skills, better identification of relapse triggers, relapse prevention skills, and improving insight into his addiction.  He was discharged with recommendations for further 24 hour inpatient substance rehabilitation treatment in a residential treatment.  

Inpatient substance rehabilitation treatment was medically necessary.  It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the patient.

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