Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient Detoxification Admission. 

The insurer denied coverage for inpatient detoxification admission. 

The denial is overturned. 

The patient is a male reportedly was admitted to inpatient detoxification treatment for detoxification treatment. He reportedly had withdrawal symptoms including nausea, tremors, sweats, anxiety, irritable mood, agitation, diffuse discomfort, and had a clinical institute withdrawal assessment (CIWA) of 12 and clinical opiate withdrawal scale (COWS) of 11. He reportedly was drinking 3 pints of wine per day, using 7-10 bags of heroin intranasally per day, and using $50 per day of crack/cocaine. His toxicology was positive for opiates, cocaine, and benzodiazepines. He reportedly had multiple past inpatient substance detoxifications. He reportedly had no clean time and was homeless and unemployed. He reportedly was started on 2 detoxification medications including Librium and Methadone. He left against medical advice (AMA) after his doses of these medications despite the recommendation to complete detoxification and then go to an inpatient substance rehabilitation 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. 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. 

According to the level of care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily including up to 3 pints of wine daily and he had active withdrawal symptoms including nausea, tremors, sweats, anxiety, irritable mood, agitation, diffuse discomfort, and had a CIWA of 12 and COWS of 11. He reportedly lacked coping skills and ability to identify relapse triggers which resulted in no abstinence time. He did require 24-hour medical hospital treatment for alcohol detoxification, it was considered unsafe for him to be treated for detoxification in a less restrictive level of care. The plan was to go to inpatient substance rehabilitation treatment after completion of this inpatient substance detoxification treatment. He reportedly left AMA after taking Librium and Methadone.  As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. 

It did not appear that the health care plan acted reasonably, with sound medical judgment, 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 the inpatient detox admission is overturned. Medical Necessity is substantiated.