Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder

Treatment: Inpatient substance detoxification

The insurer denied coverage for inpatient substance detoxification. The denial was reversed.

This male patient was admitted to inpatient treatment for alcohol and substance detoxification. He reportedly had withdrawal symptoms including tremors, sweats, muscle cramps, abdominal cramps, rhinorrhea, yawning, piloerection, irritable and anxious mood, restlessness, abnormal pupil size, malaise, and sleeping problems. He was drinking multiple sixteen ounce beers 5 times per week, snorting tens of bags of heroin 2-3 times per week, using 2-3 grams of cocaine daily, smoking 1 blunt of cannabis daily, and using 2 Percocet pills 5 times per week. He reportedly had blackouts. He had 2 past detoxification treatments and relapsed. He lacked supports. He had a positive core antibodies for a disease of the liver. He reportedly also had depression and anxiety. He was put on a Librium taper with Ativan as needed. He was discharged and was referred to inpatient substance rehabilitation treatment.

The insurer denied coverage for inpatient substance detoxification treatment as not medically necessary treatment. They stated that he did not have life threatening withdrawal, no acute medical or mental health issues requiring 24 hour inpatient substance detoxification treatment, and they recommended a less restrictive level of care.

The reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment. The chart notes did provide enough specific evidence to support that he required this level of 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. 

This was the case with this patient. This patient had multiple past substance detoxification treatments and still was using large amounts of heroin and drinking large amounts of alcohol, using Percocet, cocaine, and cannabis and was at risk for overdose due to the large amount of use. It was not likely that he could attend an outpatient substance detoxification treatment due to his continued use despite past inpatient substance treatments so he required only inpatient substance detoxification treatment.

According to the LOCADTR he did require 24 hour treatment as he needed detoxification medications including Librium to modify withdrawal and had a long history of heavy heroin and alcohol use as well as cocaine, other opiates, and cannabis use putting him at high risk for overdose and needing 24 hour treatment due to this risk. He continued to use large amounts of serious substances and alcohol so outpatient treatment for detoxification was not considered enough or safe. He needed 24 hour treatment for detoxification. He was also at risk for severe, complicated, and life threatening withdrawal due to the large amount of alcohol use. He needed detoxification medication to prevent possible life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire stay in this hospital as he had a Librium protocol and taper then and was discharged with referral to inpatient substance rehabilitation treatment. He also had comorbid depression and anxiety and lacked sober supports so outpatient detoxification then was not considered safe or likely to be effective. 

Inpatient acute hospital treatment for substance detoxification treatment was medically necessary. It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

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