Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse. 
Treatment: Inpatient rehabilitation. 
The insurer denied coverage for inpatient rehabilitation. 
The denial is overturned. 

This patient was admitted to this inpatient substance residential treatment as she reportedly was using multiple substances of use and could not maintain sustained abstinence. She reportedly was in an inpatient substance detoxification treatment prior to this treatment. She also reportedly had suicidal thoughts and plan to take any drug that would kill her. She reportedly had 2 past hospitalizations due to suicidal thoughts. She reportedly had depressed mood, hopelessness, impulsive behavior, poor coping skills, victimization of past sexual trauma, erratic behavior and had diagnoses of Bipolar Disorder and Borderline Personality Disorder in addition to Alcohol and Polysubstance Use. She reportedly was drinking alcohol, using fentanyl, cocaine, amphetamines, and psilocybin. She reportedly was taking Lamictal, Vraylar, and Wellbutrin. She reportedly was attending group and individual therapy. She reportedly was unemployed. 
  
The medical records provided enough specific evidence to support that she required this level of care. 

In this case this patient was considered in need of 24-hour residential treatment as she needed time in this 24-hour inpatient therapeutic structured and supervised setting to learn coping skills, relapse prevention skills, improve insight, better identify triggers, improve motivation, and increase sober supports. 

In this case this patient required treatment time in a 24-hour inpatient therapeutic residential treatment setting. Notes on admission reported that she was using multiple serious substances of use and had suicidal thoughts to use any drug that would kill her. She had comorbid bipolar disorder and borderline personality disorder and had poor impulse control, lack of insight into her addiction, unresolved trauma, and emotional dysregulation. Notes reported that she could not function by herself and needed support. Notes reported that she needed to work on impulse control and better emotional regulation and stated that she was a high risk for relapse due to emotional dysregulation, poor coping skills and insight into addiction, family dysfunction, and unprocessed trauma. Notes reported that Wellbutrin was increased to better target depression. This was a high-risk patient who consumed multiple serious substances of use and had serious comorbid psychiatric issues including suicidal thoughts and was considered a danger to self and in need of the entire time in this sober therapeutic supervised and structured 24-hour residential substance treatment in order to develop relapse prevention skills, strengthen coping skills, decrease impulsivity,  better identify triggers, improve insight, and increase sober supports. Without this structured and supervised therapeutic residential treatment, she likely would have relapsed quickly. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance residential rehabilitation. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for residential substance abuse treatment center is substantiated.