Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid withdrawal

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is overturned

This male reportedly was admitted to an inpatient hospital due to hypertensive urgency and chest pain. He had opioid withdrawal symptoms as well. He reportedly took intranasal heroin on the day of admission and drank alcohol. He reportedly had withdrawal symptoms including elevated blood pressure of 164/92, diaphoresis, restlessness, and anxiety. He reportedly had been in a Methadone outpatient program and was taking 100 mg (milligrams) of Methadone but stopped and took heroin. He reportedly had multiple past substance treatment episodes but continued to relapse. He reportedly also had back pain and a past seizure history. He reportedly had a diagnosis of Opioid Use Disorder. He reportedly had worsened anxiety and depressive symptoms which triggered his use. He reportedly was given Methadone 100 mg while in the hospital to help target withdrawal and cravings. He was also given Clonidine for hypertension and opioid withdrawal. He took Lisinopril and Labetalol for hypertension. 

The APA (American Psychological Association) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence, patients who relapse frequently, failure to be cooperative with or benefit from outpatient detoxification, and patients with current abuse of other substances 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. Also, the US Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment , if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. According to the LOCADTR (level of care determination) he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting. He continued to use opiates and stopped Methadone, was drinking alcohol, and had active withdrawal symptoms including elevated blood pressure of 1645/92, diaphoresis, restlessness, and anxiety. He was considered at risk for worsened withdrawal symptoms. He was at risk for overdose as he was using heroin and alcohol. He reportedly had acute medical issues including hypertensive urgency with elevated blood pressure and was at risk of worsened blood pressure and medical issues if he was not treated for the hypertension and opioid withdrawal. He did require 24-hour medical hospital detoxification treatment. It was considered unsafe for him to have detoxification at a less restrictive level of care. He was considered a medical risk due to acute medical issues and active opioid withdrawal symptoms requiring medications to treat detoxification and hypertension. 

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 inpatient admission is overturned. Medical Necessity is substantiated.