Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Detoxification from Opiates.

Treatment acute inpatient level of care.

The insurer denied coverage for acute inpatient level of care.

The denial is overturned.

This is the case of an adult female who was admitted for detoxification from opiates and benzodiazepines. She reportedly had withdrawal symptoms including nausea, vomiting, diarrhea, tremors, elevated blood pressure, chills, arthralgia and myalgia, restlessness, anxiety, cramps, flushing skin, agitation, headache, and sweats. She had a Clinical Opioid Withdrawal Score (COWS) of 16 and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 15. The patient reportedly was using intravenous (IV) heroin, was using Fentanyl up to 2 grams per day, as well as Xanax. Her toxicology was positive for opiates, cocaine, methadone, and benzodiazepines. She reportedly eloped but was brought back. The patient was put on a Methadone and Ativan taper. She was discharged.
  
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 serious substances of use including IV (4) heroin, Fentanyl, Xanax, and cocaine and was at risk for death from overdose as well as severe withdrawal. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24-hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use multiple serious substances of use with long term use, needed two detoxification medications (Methadone and Ativan) to modify withdrawal for Xanax and heroin/Fentanyl,  and she needed 24-hour treatment as she was at risk for worsened withdrawal symptoms if not in this 24-hour setting. Notes on admission reported a COWS of 16 and CIWA of 15 and reported withdrawal symptoms including nausea, vomiting, diarrhea, tremors, elevated blood pressure, chills, arthralgia and myalgia, restlessness, anxiety, cramps, flushing skin, agitation, headache, and sweats and she was started on a Methadone and Ativan taper, given IV fluids, thiamine, folate, and multivitamin. Notes reported continued withdrawal symptoms including a COWS of 6, and she required and received 2 detoxification medications still including Methadone and Ativan. She reportedly had no further withdrawal symptoms and was discharged with outpatient follow up. This patient was using multiple serious substances of use putting herself at high risk medically for overdose or severe withdrawal and she required 24-hour inpatient detoxification hospital treatment then. 

The health care plan did not act reasonably, with sound clinical judgment, or in the best interests of the patient. The medical records provided enough specific evidence to support that she required 24-hour hospital detoxification treatment. 

The insurer's denial of coverage for the acute inpatient level of care is overturned. Medical necessity is substantiated.