Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Withdrawal symptoms substance abuse
Treatment: Inpatient substance abuse admission
The insurer denied coverage for: Inpatient substance abuse admission
The denial is: Overturned
This is an adult patient was admitted to inpatient substance detoxification treatment in the hospital. The patient had withdrawal symptoms including nausea, tremors, sweats, cravings, urges, elevated heart rate of 99, anxiety, irritable mood, dilated pupils, nasal stuffiness, disorientation to date and time, visual disturbance, flushed face, and a Clinical Institute Withdrawal Assessment (CIWA) of 10 and Clinical Opiate Withdrawal Scale (COWS) of 11. The patient had 3 past overdoses including a recent one 3 months prior to admission. The patient had multiple past treatment episodes including past inpatient substance detoxification treatment as recent as 3 months ago for 5 days. The patient reportedly was in a hospital last summer after an overdose. The patient was using 1 bag of heroin intra-nasally (IN) per day and reportedly used 4 bags the day most recent to this admission. The patient had a 14-year history of use. The patient was using Alprazolam 2 milligram (mg) a few times per week and had a history of Klonopin use and had a 14-year history of Benzodiazepine use. The patient was using Buprenorphine from the street. The patient smoked marijuana 3-6 times per week and had a 28-year history of use. The patient had a positive toxicology for Opiates, Benzodiazepines, Tetrahydrocannabinol (THC), Buprenorphine, and Methadone. The patient was unemployed. The patient was put on a 5-day Methadone and Ativan protocol for detoxification treatment. The patient was discharged 5 days later to inpatient substance rehabilitation treatment level of care then for further treatment.
  
This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment when the patient was transferred to inpatient substance rehabilitation treatment level of care then for further treatment and the medical records provided did provide enough specific evidence to support that the patient required this level of care. 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 need 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. Also, the United States 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. The patient was considered at risk for severe, complicated, and life-threatening withdrawal and another overdose so the patient required 24-hour inpatient substance detoxification treatment then. The risk of delirium tremens can occur 3-7 days after Benzodiazepine use. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient substance abuse admission is substantiated.