Employee benefit plans frequently use acute care "certification criteria" to deny health insurance claims for inpatient rehabilitative treatment of alcoholism or drug dependency on grounds of "lack of medical necessity". For
example, a plan may deny an inpatient claim for 30 days treatment on grounds that the patient did not need acute detoxification beyond 3 days. Assuming that there is no plan provision limiting inpatient care to acute inpatient care or detoxification, the use of such criteria should provide no basis for denial of the claim. Detoxification is an acute care procedure, and clearly, detoxification requires inpatient treatment, but inpatient treatment is not necessarily limited to either detoxification or acute care.
Statistical evidence clearly supports the need for inpatient rehabilitative treatment. The National Drug and Alcoholism Treatment Unit Survey (NDATUS) is the only national census of specialty substance abuse (i.e. alcohol
or other drugs) treatment providers. It seeks information from all free-standing facilities that treat only substance
abuse, and from specialized substance abuse units within multi-purpose health care institutions (for example, hospitals). According to NDATUS surveys, over a twelve year period, from 1980 through 1992, inpatient confinement for detoxification accounted for only 1.6 to 2.9 percent of all treatments rendered; whereas inpatient
confinement for rehabilitation accounted for a substantial 10.8 to 13.4 percent of treatment rendered. Over half (54%) of clients in 1992 were treated in free-standing facilities that offered only outpatient substance abuse services. Most remaining clients were treated in community mental health centers (16%), general hospitals (10%), and free-standing residential facilities (7%). Across the nation in 1992, 87% of daily clients were enrolled in outpatient rehabilitation, including 75% in drug free and 12% in methadone programs. The remaining 13% were in 24-hour treatment, including 11% in rehabilitation and 2% in detoxification.
As this survey shows, of all the patients who received inpatient care for substance abuse in 1992 only 18% of those patients underwent detoxification. 82% received inpatient care geared toward rehabilitation. These percentages remain fairly constant over the twelve year period from 1980 - 1992.
Therefore, to equate the "medical necessity" for inpatient care with the need for detoxification or other acute care is to ignore approximately 80% of all patients who undergo inpatient treatment for substance abuse. Source: "Overview of the National Drug and Alcoholism Treatment Unit Survey (NDATUS): 1992 and 1980-1992" Substance Abuse and Mental Health Services Administration, Office of Applied Studies, U.S. Department of Health
and Human Services. Public Health Service. Advance Report Number 9, January 1995.)
Postscript: The federal regulations have now been amended to address the denial of claims based on undisclosed criteria. Today, any such adverse benefit determination must contain the internal rules, guidelines, protocols, standards or other similar criteria of the plan that were relied upon in denying the claim (or a statement that such criteria do not exist).
ACUTE CARE VS. REHABILITATION IN THE TREATMENT OF SUBSTANCE ABUSE
By: Michael A. McKuin
ERISA Disability Lawyer