Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This male patient was admitted for inpatient hospital treatment for substance detoxification. The patient reportedly had withdrawal symptoms including cold sweats, sleeping problems, teary of his eyes, and abdominal pain. The patient's Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score increased during admission to 12, then 14, and 16. The patient reportedly took Ativan for benzodiazepine detoxification and methadone for heroin detoxification. The patient reportedly was on a methadone protocol. The patient reportedly was also on an Ativan protocol for benzodiazepine detoxification and had extra intravenous (IV) doses of Ativan given. The patient had an electrocardiogram (EKG) showing sinus bradycardia and arrhythmia. The patient reportedly was using 25 bags of heroin per day and 1 mg of benzodiazepine daily, as well as using crack/cocaine and cannabis. 

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. In this case, this patient had use of multiple substances including heroin, benzodiazepines, as well as crack/cocaine and cannabis and was at risk for death from overdose. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use substances despite multiple past inpatient treatments including 3 past substance rehabilitation treatments. The patient also needed 2 detoxification medications to modify his withdrawal symptoms including Ativan and methadone, and even required additional IV Ativan. The patient was considered a high risk for more severe, complicated, and life-threatening withdrawal symptoms. Also this patient's CIWA score was elevating from 12 to 14, and then to 16, signaled that this patient was at high risk for life-threatening withdrawal symptoms. The patient was using large amounts of multiple substances of use and needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms. The patient would have relapsed again as evidenced by relapsing after past treatments. It was unlikely that the patient would remain abstinent while still having significant withdrawal symptoms. Thus, inpatient admission was medically necessary for this patient to stop withdrawal symptoms and to decrease the chance that he would relapse again. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for inpatient admission should be overturned. The medical necessity is substantiated.