Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a male who was admitted to this inpatient hospital treatment for detoxification from alcohol and substances abuse. He presented to the emergency room (ER). He had withdrawal symptoms including nausea, sweats, tremors, headache, insomnia, agitation, systolic blood pressure of 144, joint pain, fatigue, chills, and had a CIWA of 10. He reportedly was drinking 2 bottles of wine per day, using 10 tabs of benzodiazepine, had past heroin use, cocaine and cannabis use. He last used the morning of admission. He had a positive toxicology for cannabis. He had multiple past inpatient detoxification treatments including a recent one 1 month prior to admission. He had past jail time and had past Methadone treatment. H had a reported history of homelessness. He had a medical history significant for hepatitis, hypertension, pancreatitis, and hip pins. He had anxiety and Attention Deficit Hyperactivity Disorder (ADHD). He was put on a Lorazepam detoxification. He was discharged.

The insurer denied coverage for continued inpatient detoxification treatment in this hospital.

This reviewer disagrees with the decision to deny coverage for continued inpatient detoxification treatment in this hospital. The chart notes provided enough specific evidence to support that he required 24 hour hospital treatment for detoxification. 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 been drinking large amounts of alcohol daily and had multiple substances of use as well including benzodiazepine use, a history of heroin use, cocaine and cannabis use. He was at high risk for overdose and also for severe, complicated, and life threatening withdrawal symptoms. He had a reported history of multiple medical issues including hepatitis, hypertension, pancreatitis, and hip pins. He reportedly had an elevated CIWA and had active alcohol withdrawal symptoms. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use large amounts of alcohol and substances daily despite medical issues, legal issues, and past inpatient substance detoxification treatments. Also, he required and needed detoxification medication to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms. It was reported that he had detoxification medication (Lorazepam) to modify withdrawal and prevent more severe, complicated, or life threatening withdrawal symptoms. It was unlikely that he would remain abstinent while still having withdrawal symptoms so he required the time in this treatment
setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24 hour setting and also to prevent possible life threatening withdrawal symptoms.

As a result, the determination is to reverse the previous decision and approve coverage for continued inpatient substance detoxification. It did not appear that the health care plan acted reasonably or in the best interests of the patient. 

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