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 this inpatient hospital treatment for detoxification treatment.  He reportedly had withdrawal symptoms that included tremors, diarrhea, nausea and vomiting, abdominal pain, difficulty sleeping, joint pain, moist eyes, flushed face, dilated pupils, anxiety, and irritable mood and he had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 12 and Clinical Opiate Withdrawal Scale (COWS) of 17.  He reported using up to 30 bags of heroin and Xanax 6 mg per day for 19 years, as well as Methadone, cocaine, and alcohol. He had a history of multiple past inpatient detoxification treatments and past inpatient substance rehabilitation treatments.  He reportedly was homeless and had legal charges pending. He reportedly had hepatitis C.  He had a positive toxicology for cocaine, benzodiazepines, and barbiturates.  He was treated with an Ativan and Methadone protocol. The patient reportedly left against medical advice (AMA).

In this case this patient had been using multiple serious substances of use in large amounts including up to 50 bags of IV heroin per day, 6 mg of Xanax per day, Methadone, and alcohol  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 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 alcohol despite past multiple inpatient detoxification and rehabilitation treatments, he required and needed 2 detoxification medications including Ativan and Methadone which he reportedly took for substance and alcohol 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 or benzodiazepine use so he required at least the entire time in this inpatient substance hospital detoxification treatment.  He reportedly continued to use multiple serious substances of use despite negative consequences including legal problems and arrests and medical problems including hepatitis C, poor dentition, track marks, and anemia.  He also reportedly lacked coping skills and ability to identify relapse triggers and he had comorbid psychiatric issues including attention deficit hyperactivity disorder (ADHD) as well as the comorbid medical issues, and he reportedly was homeless, had no family support, and lacked a sober support system, and could not maintain abstinence.  He was considered a high risk patient medically for overdose and severe, complicated and life threatening withdrawal.  


It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient then.  

The carrier's denial of coverage for the inpatient substance abuse admission is overturned.  The medical necessity is substantiated.