Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Addiction
 
Treatment: Inpatient substance detoxification admission

The insurer denied the Inpatient Admission. The denial was reversed.  

This is a male patient was admitted to this inpatient substance detoxification treatment in early 2019, and then to substance rehabilitation treatment after. He was using multiple bags of heroin per day, cocaine, Oxycodone, and tetrahydrocannabinol (THC) and had a Clinical Opiate Withdrawal Scale (COWS) score of 3 during that admission. He had refused Methadone detoxification medication during admission however; he took Suboxone for detoxification for only one day. He then had rehabilitation treatment to try to improve coping and relapse prevention skills, as well as to better identify high risk relapse situations. It was noted that the patient lived alone. He had a history of anxiety, depression, grief, and trauma. He was self-referred as he wanted help to stop using substances. He was then discharged. 

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. According to the Level of Care for Alcohol and Drug Treatment Referral, LOCADTR, he did require 24-hour treatment as he needed detoxification and received detoxification medication with Suboxone to modify withdrawal and prevent moderate to severe withdrawal. Additionally, he still had reports of withdrawal with a COWS score of 3. Also, he was at risk for moderate to severe withdrawal, as well as overdose due to his large amount of opiate use. He was considered in need of 24-hour substance rehabilitation treatment as he needed help improving coping and relapse prevention skills and needed to better identify high risk relapse situations. He also had psychiatric issues, including anxiety, depression, grief, and trauma. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case, this patient was considered in need of 24-hour substance rehabilitation treatment as he was using multiple serious substances in large amounts, including multiple bags of heroin per day, cocaine, Oxycodone, and THC. He was at risk for overdose and severe withdrawals. Also, the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that the best treatment outcomes occur with longer durations of treatment. It also states that recovery from drug addiction is a long term process and that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates. In this case, this patient required this 24-hour inpatient substance rehabilitation treatment from as he was considered a high risk for relapse and continued use due to his poor coping skills, difficulty identifying relapse triggers, and comorbid depressive and anxiety symptoms. 

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is substantiated.  The insurer's denial is reversed.