Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

This patient is a male was admitted to inpatient detoxification treatment for detoxification of heroin and Xanax. He had a five year history of heroin use including using up to 100 bags per day and also a 10 year history of using up to 5 pills of Xanax per day, as well as cannabis use. He had legal charges pending and past inpatient substance detoxification and rehabilitation treatments in the past few years.  He presented with withdrawal symptoms including sweats, tremors, joint pain, teary eyes, back pain, irritable mood, and anxiety, as well as sleeping problems and had a Clinical Opiate Withdrawal Scale (COWS) of 11 and Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 10. He was put on an Ativan and Methadone protocol and had these two detoxification medications for several days and then discharged the day after the last dose.

The insurer denied coverage for inpatient detoxification treatment in the hospital as not medically necessary treatment. This reviewer disagrees with the decision to deny coverage for inpatient detoxification treatment in the hospital. The chart notes did provide enough specific evidence to support that he needed this level of care. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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 very large amounts of heroin daily including up to 100 bags per day and using 5 Xanax pills per day putting him at high risk for overdose as well as severe, complicated, or life threatening withdrawal. 

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 in outpatient detoxification settings as he continued to use large amounts of serious substances. He also required and needed 2 detoxification medications for a specified date range to modify withdrawal symptoms and needed 24 hour treatment, as he was at risk for worsened withdrawal symptoms if not participating in this 24 hour setting, including life threatening withdrawal or overdose. 

The risk of life complicated withdrawals such as delirium tremens can occur 3-4 days to one week after benzodiazepine use, so he required the entire time including for detoxification treatment. He continued with withdrawal symptoms including sweats and nausea as per notes on two specified dates that reported that he still complained of withdrawal symptoms. Also, he likely would have relapsed again as evidenced by relapsing after multiple past inpatient treatments. It was unlikely that he would remain abstinent while still having withdrawal symptoms so he required the time in this treatment setting and decrease the chance that he would relapse again when not in this 24 hour setting and also to prevent possible severe or life threatening withdrawal symptoms or overdose. 
  
Inpatient substance detoxification was not medically necessary. The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient.  

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is reversed.