Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol and substance Use

Treatment: inpatient substance detoxification service

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

This patient is a male, who was admitted to this inpatient substance detoxification treatment for alcohol and heroin detoxification treatment.  He had withdrawal symptoms including stomach cramps, flushing and chills, dilated pupils, high blood pressure and heart rate of 160,100, and 101, bone and joint discomfort, nasal stuffiness, and moist eyes. He reportedly was drinking 2 pints of vodka per day with a 40 year history and inhaling 8-10 bags of heroin per day. He reportedly had a history of suicidal ideation and mood symptoms.  He had pending legal issues.  He reportedly had past substance detoxification treatment.  He reportedly had 2 detoxification medications including; Methadone and Valium.  He was referred to inpatient substance rehabilitation treatment and discharged.

The insurer denied coverage for continued inpatient substance detoxification treatment, as not medically necessary treatment. They stated that he had no history of withdrawal seizures or delirium, and that after a specified date he had Clinical Opiate Withdrawal Scale (COWS) and Clinical Institute Withdrawal Assessment of Alcohol (CIWA) scores of 1. 

This reviewer disagrees with the decision to deny coverage for continued inpatient substance detoxification treatment. He was discharged. 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, the patient had use of multiple substances including heroin and alcohol and was at risk for death from overdose.  

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 substances despite multiple past inpatient substance detoxification treatments, needed two detoxification medications including Methadone and Valium to modify withdrawal from alcohol and heroin, had long term multiple substances of use including using heroin and alcohol , continued to use despite legal consequences, and he needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then, and he likely would have relapsed again as evidenced by relapsing after past treatments.  He also had comorbid psychiatric issues including depression and suicidal ideation.  He was at risk for severe, life threatening, and complicated withdrawal including delirium tremens which could occur four days after stopping use. He had a 5 day Methadone and Valium taper which reportedly was completed and was then referred to inpatient substance rehabilitation treatment. It also was necessary to get detoxification treatment prior to inpatient substance residential treatment and he could not successfully be detoxified in an outpatient setting.  

As a result, the determination is to reverse the previous decision and approve coverage for continued inpatient substance detoxification. It did not appear that the health care plan acted reasonably, with sound medical judgment or in the best interests of the patient.

The carrier's denial of coverage for the inpatient detoxification service is reversed. The medical necessity is substantiated.