Question: My insurance company is giving me the run around, while attempting to get into inpatient dual-diagnosis rehab. They are not responding to the different facility who are attempting to get claims approved. Today I'm finally picking up my referral from an in-network psyc dr. for in patient rehab. What key elements need to occur for insurance companies to have no choice but to authorize treatment?

Dr. David Sack Says...:

There are several factors related to meeting "medical necessity" for treatment:

1. The amount/frequency of Drug/Alcohol  use and/or the need for a medically monitored detox
2. Recent failure of treatment at a lower level of care (for example, outpatient treatment)
3. The presence of a co occurring disorder such as diagnosed clinical depression or anxiety
4. Medical problems and medication history
5. Legal issues related to use
6. Family or work problems related to use
7. Employment that combined with substance abuse puts self or others in jeopardy, for example Nurse or Pilot. 

Not all of these examples are required however your assessment must demonstrate the severity of your problem in order to meet the insurance companies criteria for residential treatment. 

Question: My 26 year old brother has rapid cycling bipolar disorder and about 2 years ago he attempted suicide. After his suicide try, he was sort of stabilized on medications and he stayed on them for a while, but I can tell now that he’s off them again and he seems to be using crack or meth or something as well. I’m really scared for him but he says he’s fine and doesn’t need or want any help, of any kind – and he gets so aggressive when anyone pushes the issue that everyone in the family is scared to bring it up anymore. A few days ago he was acting crazy and smashing his stuff up in front of the room he rents (my parents pay the rent) and the police came and he calmed down so they didn’t press any charges. We explained the situation and asked if they’d take him in for his own good to get him some help but they said they can’t unless he’s obviously just about to hurt himself or someone else. He’s acting just like he did before his last suicide attempt so we think he is about to hurt himself but he won’t listen to us and he won’t take his medication. Is there any way we can get him hospitalized for his own safety, even though he doesn’t want to go?

Dr. David Sack Says...:

The rules about civil commitment
vary from state to state. Over the last 30 years the civil rights of the
identified patient have been given much more weight in the equation. So it has
made it much harder to put them into treatment on an involuntary basis. In
general, psychiatric patients can only be detained for very short periods of
time, 72-96 hours, for the purposes of assessment. If they are deemed to be an
imminent threat to themselves or other people involuntary treatment can be
provided.

In general, the courts have been
reluctant to keep patients in involuntary treatment who state they are willing
to accept treatment and have a place to go to. The problem you are encountering
with your brother is all too common across the United States today. Some
jurisdictions have enacted outpatient civil commitment to ensure the individual
stays in treatment after they are released from the facility – but this is the
exception rather than the rule.

If you can be present when the
police are called to your brother’s house there is a much greater likelihood
that they will be willing to detain him and bring him to treatment. However,
this is often not possible or feasible. 

Many patients who are stable in
their bipolar disorder will become unstable or psychotic even after very brief
exposure to crack or methamphetamines. It is critical your brother receive
treatment not only for his bipolar disorder, but for his substance abuse, if
there is any chance for him to stabilize long term. In many cases where
treatment appears to not be working, the person shows dramatic improvement if
they stop using illicit drugs or alcohol.

One treatment, lithium, has been
shown to significantly decrease suicidal risk in bipolar patients with this
clinical picture.