Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid and Benzodiazepine Detoxification

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned.

This patient was admitted to this inpatient hospital treatment due to opioid and benzodiazepine detoxification as well as intravenous (IV) antibiotic treatment for a brachial abscess. He reportedly had active alcohol withdrawal symptoms and infection including fever/chills, nausea, vomiting, increased heart rate over 100, diarrhea, abdominal pain and discomfort, and he had a past benzodiazepine withdrawal seizure. He was using 8 mg (milligrams) of Xanax per day and 8 mg of Clonazepam per day as well as 15 bags of IV heroin, fentanyl, and morphine, and IV cocaine up to 1 gram per day. He reportedly had hepatitis C. He reportedly had comorbid mental health conditions including depression and post traumatic stress disorder (PTSD) and had a past psychiatric hospitalization for cutting. He had multiple past psychotrophic medication trials. He reportedly had 3 recent overdoses. He had a recent hospital and also had suicidal ideation and he left AMA (against medical advice). He was given Methadone 40 mg per day and an additional 20 mg per day for opioid detoxification treatment, Clonazepam 2 mg per day and 1 mg twice per day as needed for benzodiazepine detoxification treatment. He was reportedly in a Methadone clinic for past treatment and had past Methadone, Suboxone, and Vivitrol treatment. He had IV fluids, IV antibiotics, and had a creatinine of 2.4 and reported burning chest pain. He had acute kidney injury, hyperkalemia with suspicion of infective endocardititis and was at significant risk for acute withdrawal. He was discharged to a shelter with referral to a Methadone clinic and outpatient Psychiatry appointment.
 
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. It also states that patients with past complicated or life threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

The US (United States) Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment , if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. 

He was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including more severe, complicated, and even possible life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at risk for this. He also was at risk for overdose again due to the large amount of daily benzodiazepine, heroin, fentanyl, and morphine, and cocaine use. He was considered very high risk for life threatening withdrawal and was an acute medical risk in need of 24 hour hospital treatment then. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.