Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Use Disorder

Treatment:  Inpatient substance abuse

The insurer denied coverage for inpatient substance abuse.  The denial was reversed.

This patient is a male was admitted to this inpatient substance detoxification treatment due to alcohol, benzodiazepine, and heroin withdrawal and the need for detoxification treatment.  He had withdrawal symptoms, including sweats, chills, an increased heart rate of 99, back pain, and restlessness.  He had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 6 and a Clinical Opiate Withdrawal Scale (COWS) score of 8.  He was using multiple bags of intravenous (IV) heroin per day, drinking 1 pint of alcohol and two 24 ounces per day, and using 2 mg of Xanax 4 per day.  He had 15 prior inpatient detoxification treatments with the last one in 2018 and 5 prior substance rehabilitation treatments.  He lived in an apartment.  He was put on a Methadone and Klonopin taper and was then discharged with a referral to inpatient substance rehabilitation treatment.

The insurer denied coverage for inpatient substance detoxification treatment as not medically necessary.  They stated that he had only mild withdrawal, had no acute medical or mental health issues requiring 24-hour inpatient detoxification treatment, and they recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment as the chart notes did provide enough specific evidence to support that he required this level of treatment.  The American Psychiatric Association (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.  This was the case with this patient.  This patient had multiple prior substance detoxification treatments and was still using very large amounts of IV heroin daily, as well as using Xanax and drinking large amounts of alcohol.  He was at high risk for overdose and severe, complicated withdrawals.  It was not likely that he could attend an outpatient substance detoxification treatment due to his continued use, despite so many prior inpatient substance treatments; therefore, he required inpatient substance detoxification treatment.  Also, according to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he needed two detoxification medications including Methadone and Klonopin to modify withdrawal.

As a result, reverse the previous decision and approve coverage for inpatient acute hospital treatment for substance detoxification.  The health care plan did not act reasonably, or with sound judgment, or in the best interests of the patient.  

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