Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient chemical dependency detoxification admission

The insurer denied coverage for the inpatient chemical dependency detoxification admission.
The denial is overturned. 

This is a male patient with a history of cannabis dependence, nicotine abuse, alcohol abuse, cocaine abuse, insomnia presented to the hospital for complaints of alcohol withdrawal and seeking detoxification. He was admitted with withdrawal symptoms. He reportedly had tremors, sweats, sleeping problems, irritable mood, anxiety, had a Clinical Institute of Withdrawal Assessment (CIWA) score of 11, and a clinical Opioid Withdrawal Scale (COWS) score of 5. He reportedly was drinking six 24 ounce beers per day and half pint of brandy per day, and smoking two blunts per day. He reportedly had past multiple inpatient detoxification treatments as well as an inpatient substance rehabilitation treatment for 14 days. He reportedly was put on a Librium protocol and took Librium for the current detoxification treatment and was discharged on day 6 of admission. The discharge plan was to follow up with inpatient rehabilitation treatment so he was discharged and then reportedly went to inpatient substance rehabilitation treatment. 

The American Psychiatric Association 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 as he had continued using large amounts of alcohol including drinking six 24 ounce beers per day and half pint of brandy per day, and smoking 2 blunts per day with a 33-34 year history of use. He reportedly lacked coping skills and the ability to identify relapse triggers and was unemployed. He reportedly had a positive toxicology for tetrahydrocannabinol (THC) and benzodiazepines. He could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use alcohol and substances after inpatient detoxification and rehabilitation treatments. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient 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 large amounts of alcohol despite multiple past inpatient detoxification and rehabilitation treatments. He reportedly had active withdrawal symptoms including tremors, sweats, sleeping problems, irritable mood, anxiety, had a CIWA score of 11 and COWS score of 5, and needed detoxification medication (Librium) to modify withdrawal, had long term multiple substances of use, and he needed 24 hour treatment then as he was at high risk for worsened withdrawal symptoms if not in this 24 hour setting then and he likely would have relapsed again as evidenced by relapsing after past inpatient substance treatments. He reportedly was at risk of more severe, complicated, or life threatening withdrawal including delirium tremens which can occur 3-4 days after use so he required the entire time. The patient required this inpatient detoxification treatment in this hospital setting prior to inpatient substance rehabilitation. 

It did not appear that the health care plan acted reasonably or with sound medical judgment or in the best interests of the patient then.

The carrier's denial of coverage for the inpatient chemical dependency detoxification admission is overturned. The medical necessity is substantiated.