Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment medically supervised inpatient detoxification services

The insurer denied coverage for medically supervised inpatient detoxification services

The denial is overturned

This male was admitted to this inpatient substance detoxification treatment in this medically supervised inpatient detoxification treatment for detoxification treatment. The patient had withdrawal symptoms including diarrhea, tremors, nervousness, irritable mood, agitation, insomnia, chills/flushing, dilated pupils, diffuse discomfort, nasal stuffiness, nausea, and loose stools, and had a COWS [Clinical Opiate Withdrawal Scale] of 12 and CIWA [ Clinical Institute Withdrawal Assessment] of 9. He reportedly was using 7-10 bags of intranasal heroin per day, using 2 mg (milligrams) of Xanax per day, 4 blunts of cannabis per day, $50 per day of cocaine 1-2 times per week, and drinking 2 beers/2 nips per day. The patient had a positive toxicology for opiates, cocaine, benzodiazepines, and THC [tetrahydrocannabinol]. He reportedly had multiple past inpatient detoxification treatments and had inability to maintain abstinence and lacked coping skills for abstinence. He had comorbid PTSD (post-traumatic stress disorder) and bipolar disorder. The patient was put on a 5-day Ativan and Methadone taper but left AMA (against medical advice) prior to completing treatment.
    
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. 

According to the LOCADTR [Level of Care for Alcohol and Drug Treatment Referral] , the patient did require 24-hour treatment as he could not safely and effectively be treated in less restrictive detoxification settings, as he continued to use large amounts of multiple serious substances of use. He reportedly had been using large amounts of multiple serious substances of use including heroin, cocaine, alcohol, Xanax, and cannabis and had active withdrawal symptoms. He reportedly had withdrawal symptoms including diarrhea, tremors, nervousness, irritable mood, agitation, insomnia, chills/flushing, dilated pupils, diffuse discomfort, nasal stuffiness, nausea, and loose stools, and had a COWS of 12 and CIWA of 9 and required and received 2 detoxification medications including Ativan and Methadone. He was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including severe and life-threatening withdrawal symptoms. He reportedly could not maintain any abstinence despite multiple past inpatient substance detoxification treatments including 4 inpatient detoxification treatments. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol/benzodiazepine and he was at risk for severe withdrawal as well due to the large amount of substance use, so he required the entire time in this medical inpatient detoxification setting when he left AMA despite the recommendation for a 5-day inpatient detoxification treatment in this hospital setting. The patient reportedly lacked coping skills for abstinence and could not safely and effectively be treated in a less restrictive setting. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance/alcohol detoxification in this hospital setting. 

The health care plan did not act reasonably, with good clinical judgment, or in the best interests of the patient. The medical records provided enough specific evidence to support that he required this level of care.

The insurer's denial of coverage for the medically supervised inpatient detoxification services is overturned. Medical necessity is substantiated.