Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opiate Abuse. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

This patient reportedly was admitted to this inpatient hospital for detoxification as they reportedly had opioid withdrawal symptoms. The patient reportedly had a Clinical Opiate Withdrawal Scale (COWS) of 11 and had withdrawal symptoms including elevated heart rate of 110, tremors, irritable mood, anxiety, dilated pupils, and diffuse discomfort. The patient reportedly was using 4-5 bags of intravenous (IV) heroin daily with a 38 year history of use. The patient also reportedly was smoking one joint of cannabis daily with a 45 year history. The patient reportedly had hepatitis C and malnutrition due to substance use. The patient reportedly was unemployed. The patient reportedly had so many inpatient detoxification treatments until this one and left some against medical advice (AMA) and also had some inpatient substance rehabilitation treatments and was still unable to maintain abstinence. The patient reportedly was put on a Methadone protocol and received Methadone. The patient reportedly left AMA. 
  
The medical records provided enough specific evidence to support that the patient required this level of car. 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 been using large amounts of heroin daily including up to 5 bags of IV heroin per day and cannabis daily and the patient was at risk for death from overdose of heroin and also at risk for severe withdrawal. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient did require 24-hour treatment as they could not safely and effectively be treated for detoxification in a less restrictive setting as they continued to use large amounts of heroin daily including up to 5 bags of heroin daily IV despite so many past inpatient substance detoxification treatments and some past inpatient substance rehabilitation treatments. Also, the patient required and received detoxification medication, Methadone, to modify withdrawal from heroin, had long term multiple substances of use including using heroin and cannabis, and needed 24-hour treatment then as they were at risk for worsened withdrawal symptoms including severe withdrawal and even overdose. The patient reportedly had active withdrawal symptoms including elevated heart rate of 110, tremors, irritable mood, anxiety, dilated pupils, and diffuse discomfort and had a COWS of 11. The patient likely would have relapsed again as evidenced by relapsing after so many past inpatient substance detoxification treatments and some past inpatient substance rehabilitation treatments. The patient reportedly lack coping skills, relapse prevention skills, ability to identify relapse triggers, and also lacked a sober support network to maintain abstinence. The patient also had reports of medical issues related to substance use including malnutrition and hepatitis C. 

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 an inpatient admission is substantiated.