Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use
 
Treatment: Inpatient substance detoxification 

The insurer denied coverage for inpatient substance detoxification treatment. The denial is reversed. 

This patient is a male who was admitted due to withdrawal symptoms and the need for inpatient detoxification treatment.  He reportedly had nausea, sweats, abdominal pain, diarrhea, shortness of breath, anxiety, irritable mood, blood pressure of 155/90, and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 10.  He had reported medical issues including congestive heart failure (CHF), hypertension, traumatic brain injury (TBI), and hepatitis B.  He had a high creatinine of 1.36 and BUN of 27.  He was drinking at least 1 pint of liquor per day, using tens of dollars' worth of cocaine per day, and also was using opiates and cannabis as his toxicology was positive for opiates, cocaine, and cannabinoids.  He reportedly had multiple past inpatient substance detoxification and rehabilitation treatments but still relapsed.  He reportedly was put on a Librium taper protocol and had Ativan ordered as needed as well, had intravenous (IV) hydration, IV Pepcid, continuous Lasix, Protonix, and Procardia.  He reportedly was discharged.

The insurer denied coverage for continued inpatient substance detoxification treatment as not medically necessary treatment. This reviewer disagrees with the decision to deny coverage for continued inpatient substance detoxification treatment as the chart notes provided enough specific evidence to support that he required this level of treatment then.  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, 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 reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

This patient could not safely be treated in a less restrictive setting than inpatient medical hospital including a subacute inpatient setting as he reportedly had active withdrawal symptoms putting him at risk for severe, life threatening, and complicated withdrawal, and he had comorbid medical conditions rendering him not safe for detoxification other than this inpatient hospital detoxification.  He was at risk for severe, life threatening, and complicated withdrawal including withdrawal seizures or delirium tremens as the risk of delirium tremens (DT's) is higher for the first five days after cessation of use.  

According to the Level of Care for Alcohol and Drug Treatment Referral (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, cocaine, and used opiates and cannabis despite medical issues and despite multiple past inpatient substance detoxification and rehabilitation treatments.  Also, he required and needed detoxification medication including Librium to modify withdrawal and to prevent more serious withdrawal and had comorbid medical conditions complicating the management of withdrawal so it was not likely that he could safely be managed in a less restrictive setting other than this inpatient hospital detoxification treatment. 
 
It did not appear that the health care plan acted reasonably or in the best interests of the patient then.  

The carrier's denial of coverage for the Medically Supervised Inpatient Withdrawal and Stabilization Services is reversed.  The medical necessity is substantiated.