Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment inpatient substance abuse detoxification

The insurer denied coverage for inpatient substance abuse detoxification.
The denial is overturned.

This patient was admitted to inpatient hospital treatment for detoxification as he had withdrawal symptoms including nausea and vomiting, sweats, tremors, irritable mood, anxiety, restlessness, headache, visual hallucinations, and cravings. He had a Clinical Institute Withdrawal Assessment Scale (CIWA) of 11 on admission and then 14. He was drinking 4 pints of vodka per day, inhaling 3-4 bags of cocaine per day, smoking 3 blunts of marijuana, and had a positive toxicology for cocaine, tetrahydrocannabinol (THC), and Xanax. He reportedly had 5 past unsuccessful inpatient detoxifications. He also had hypertension. He also had comorbid depressive and anxiety symptoms including panic attacks, hopelessness, mood swings, decreased appetite, and difficulty sleeping. He reportedly lived alone and lacked social supports. He took Vistaril and Melatonin. he reportedly was put in a CIWA protocol but left against medical advise (AMA) due to concerns about his job and residence.

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. This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life-threatening withdrawal due to large amounts of daily alcohol use including 4 pints of vodka per day and Xanax use, as well as cocaine use which put him at risk medically requiring hospital detoxification. 

Notes reported withdrawal symptoms including nausea and vomiting, sweats, tremors, irritable mood, anxiety, restlessness, headache, visual hallucinations, and cravings with a CIWA of 11. Notes reported a CIWA as high as 14 with continued withdrawal symptoms including headache, auditory hallucinations, sweats, tremors, nausea, anxiety, restlessness, tension, irritable mood, decreased appetite and concentration problems. Other documentation reported a CIWA as high as 13 with continued withdrawal symptoms including sweats, tremors, headache, visual hallucinations, irritable mood, anxiety, and tension. He reportedly left AMA. He was considered a high risk medically and in need of hospital treatment for detoxification from alcohol, Xanax, cocaine, and cannabis/hashish and was on a detoxification protocol. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment for detoxification. It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

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

The insurer's denial of coverage for inpatient substance abuse is overturned. Medical Necessity is substantiated.