Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was overturned.

This is a male patient who was admitted to the hospital for inpatient substance detoxification treatment. He had reports of withdrawal symptoms that included nausea, tremors, lightheadedness, sleeping problems, irritable mood, and anxiety, and had a CIWA of 11 and COWS of 10. He reportedly was drinking three 6 packs of beer per day, snorting 10-12 bags of crack per day, and using heroin 1 bag inhaled. He reportedly had multiple past inpatient substance detoxification treatments and past inpatient rehabilitation treatment. He reportedly had a significant history of alcohol use. He reportedly was put on a Librium protocol for detoxification treatment and left against medical advice (AMA).
  
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 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. In this case this patient had been using multiple serious substances of use in large amounts including drinking three 6 packs of beer per day, sorting 10-12 bags of crack per day, and using heroin 1 bag inhaled and he was at high risk for overdose as well as severe, complicated, and life threatening withdrawal symptoms so he required inpatient substance detoxification treatment in this hospital then.

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 alcohol, crack, and heroin despite past multiple inpatient detoxification and rehabilitation treatments. He required and needed detoxification medication including Librium which he required until discharge for detoxification treatment. He was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required at least the entire time in this inpatient substance hospital detoxification treatment. He was considered a high risk patient medically for overdose and severe, complicated and life threatening withdrawal. He reportedly left AMA before the detoxification treatment was complete but he did require the detoxification treatment. 

It did not appear that the health care plan acted reasonably, with sound medical judgment, 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 overturned.