Diagnosis: Substance Abuse Treatment: Admission for Inpatient Substance Rehabilitation Treatment The insurer denied the coverage. The denial was reversed. This male patient was admitted to inpatient substance rehabilitation treatment in mid-2018. He was reportedly using 1 bag of heroin per day and $25 of cannabis per day with last use on the day of admission. He was using heroin since age 25 and cannabis since age 16. He reportedly had family conflicts due to substance use, spent time with drug seeking behaviors, was unemployed, and unable to gain employment as a result. He reportedly could not maintain abstinence on his own and lacked insight into addiction. He reportedly had past inpatient substance detoxification treatment. He was homeless and was transferred to another inpatient substance rehabilitation treatment in mid-2018. The insurer denied coverage for inpatient substance rehabilitation treatment, as not medically necessary treatment. They stated that he did not have dangerous withdrawal, medical or mental health issues requiring 24 hour treatment, and they recommended a less restrictive level of care then. According to the LOCADTR he met criteria for substance residential treatment as he continued to use multiple substances despite treatment past inpatient substance treatment settings and he had positive toxicology for THC and opiates and lacked supports as he was homeless. The 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 the patient was considered in need of 24 hour residential treatment as he was discharged to another inpatient substance rehabilitation treatment. The patient lacked insight into their addiction and needed better coping skills, identification of relapse triggers, was unable to maintain abstinence on his own without this 24 hour therapeutic setting, needed more insight into addiction, was homeless and lacked supports for treatment as an outpatient.

1) The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use