Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient Substance Abuse Services
The insurer denied the Inpatient Substance Abuse Services. The denial was reversed. 

This is a male patient who was admitted to inpatient substance detoxification treatment for alcohol and heroin detoxification treatment. He had withdrawal symptoms including tremors, nausea, irritable mood, anxiety, teary eyes, diarrhea, elevated heart rate of 95, elevated systolic blood pressure of 130, and a CIWA of 10. He had a positive toxicology for opiates, cocaine, and benzodiazepines and a blood alcohol level of 0.4. The patient reported that he was homeless and lacked coping skills, and a sober support system. He had a history of numerous past inpatient substance detoxification and rehabilitation treatments. He reportedly had a 29 year history of alcohol use; drinking 12 beers per day. He also reported daily crack use as well as benzodiazepines. He was put on a Librium protocol during his inpatient admission but left against medical advice.

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had use of multiple serious substances of use including heroin, alcohol, and benzodiazepines. He was at high risk for death from overdose and severe, complicated, and life threatening withdrawal. According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use substances despite numerous past  inpatient detoxification and rehabilitation treatments. Also, he needed detoxification medication to modify withdrawal including Librium.

The patient lacked the coping skills. The patient had reported Schizoaffective Disorder also. It was unlikely that he would remain abstinent while having withdrawal symptoms. He had reports of withdrawal symptoms including tremors, nausea, irritable mood, anxiety, teary eyes, diarrhea, elevated heart rate of 95, and elevated systolic blood pressure of 130. His CIWA score was 10 initially so he required the time in this treatment setting. The patient could not safely and effectively be treated for detoxification in an outpatient setting as he likely would still would use alcohol, benzodiazepines, and crack if not in a 24 hour setting for detoxification. The risk of delirium tremens can occur even 4 days after stopping alcohol use and this is considered a life threatening withdrawal so he was still considered at risk. The patient continued to require and receive detoxification medications for modification of withdrawal and prevention of worsened withdrawal as it was reported that he received Librium.

Based on the above, the medical necessity for the inpatient substance abuse services is substantiated.  The insurer's denial is reversed.