Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use

Treatment: Inpatient rehabilitation admission

The insurer denied coverage for the inpatient rehabilitation admission.

The denial is overturned.

This is a male patient who was admitted to inpatient substance rehabilitation treatment after being referred from his men's residential treatment. The patient reportedly was drinking 24 ounces of alcohol daily and smoking 2 blunts of cannabis daily. The patient reportedly had a past substance detoxification. The patient reported past legal issues including cannabis possession. The patient lacked supports and was unemployed after losing his job. The patient reportedly minimized his addiction. As an inpatient, the patient was compliant to treatment, and attended individual and group therapy. 

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 24-hour residential treatment then as he lacked insight into the seriousness of his addiction and continued to use alcohol and cannabis daily despite past legal issues due to this use and despite past inpatient substance treatment. 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 alcohol and cannabis daily despite past legal issues due to this use and despite past inpatient substance treatment. The patient reportedly had legal issues in the past related to his use and lacked supports. The chart notes reported that the patient was working on trying to confront his denial and minimization of use, improve coping skills and relapse prevention skills, and better identify triggers to use while improving insight into use. The patient still reportedly was working on identification of triggers and working on improving his sober support system as reported in the second week of treatment. 

Also, the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide, reports that research indicates that the best treatment outcomes occur with longer durations of treatment and states that recovery from drug addiction is a long term process. It also states that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. In this case, this patient needed the entire time in this 24-hour therapeutic supervised and structured treatment setting to learn better coping skills and relapse prevention skills, decrease impulsivity, increase supports, improve insight, confront denial and minimization. Thus, the 3 weeks of treatment was considered medically necessary to further progress and sustain any gains and to better ensure abstinence upon discharge to a less restrictive level of care.  Without this structured and supervised therapeutic residential treatment, the patient likely would have relapsed again. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient substance residential treatment.

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 substantiated. The insurer's denial should be overturned.