Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Medically Supervised Inpatient Withdrawal and Stabilization Services
 
The insurer denied the medically supervised inpatient withdrawal and stabilization services.

The denial was overturned.

This is a female patient who was admitted to this inpatient hospital for detoxification treatment from alcohol and heroin.  She had withdrawal symptoms and had a Clinical Opiate Withdrawal Scale (COWS) score of 6 and a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 4.  She reported drinking 3-4 liters of vodka and wine per day, using 5-15 bags of intranasal heroin per day, and using 1-2 grams of intranasal cocaine; she had two prior overdoses.  She had prior inpatient substance detoxification and rehabilitation treatment and still was unable to stop use.  She had depressive symptoms and self-injurious behavior including cutting herself.  It was reported that she stopped her psychotropic medications.  She was put on two detoxification medications.  She was discharged to the Emergency Department when she expressed suicidal plans to overdose or cut a vein. 

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 states 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.  They report that patients with co-morbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification.  The US 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.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), she required 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting.  She was put on two detoxification medication protocols to modify withdrawal from alcohol and heroin, and she had active reported withdrawal symptoms and was at risk of severe, complicated, and life-threatening withdrawal, as well as overdose.  She had two past overdoses; therefore, she was a high risk for another overdose.  She had self-injurious behavior including cutting herself and had comorbid depression with suicidal ideation.  She had two suicidal plans including overdose and cutting her vein.  She was discharged to the Emergency Department (ED) for psychiatric assessment.  She needed 24-hour treatment as she was at risk for worsened withdrawal symptoms if not in this 24-hour setting, 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.  She did require 24-hour medically supervised inpatient withdrawal treatment.  It was considered unsafe for her to have detoxification at a less restrictive level of care.  

The health care plan did not act reasonably, or sound medical judgment, or in the best interests of the patient.

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