Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment is inpatient substance detoxification treatment
The insurer denied coverage for inpatient substance detoxification treatment
The denial is overturned

This patient reportedly was admitted to this inpatient treatment center for detoxification treatment. He reportedly had withdrawal symptoms including tremors, nausea, sweats, nervousness, irritable mood, insomnia, cravings, and had a CIWA (Clinical Institute Withdrawal Assessment Alcohol) of 8. He reportedly was drinking 1-2 pints of liquor per day, using 10 bags of intravenous (IV) heroin per day, $60 of IV cocaine per day, and smoking 1 joint per week. He reportedly had a positive toxicology for opiates, cocaine, methadone, and THC (Tetrahydrocannabinol). He reportedly was in a methadone maintenance program and was referred by them due to multiple positive toxicology tests. He reportedly had multiple past inpatient substance treatments and could not maintain abstinence. He reportedly was homeless and unemployed. He reportedly was put on an Ativan taper protocol and was prescribed Clonidine as needed and was taking 110 mg (milligrams) of Methadone. He reportedly was discharged to inpatient substance rehabilitation treatment.
    
The reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment as the medical records provided enough specific evidence to support that he required this level of care then. 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. In this case this patient had been drinking large amounts of alcohol daily including up to 1-2 pint of liquor per day and could not stop use despite past inpatient substance treatments. He reportedly was using multiple serious substance so fuse in large quantities daily including drinking 1-2 pints of liquor per day, using 10 bags of IV heroin per day, $60 of IV cocaine per day and was at risk medically for an overdose and also for severe, complicated, and life-threatening withdrawals such as delirium tremens. 

He reportedly lacked supports as he was homeless and unemployed and continued with intense cravings, so he was at high risk for relapse. It was unlikely that he would remain abstinent while still having withdrawal symptoms so he required the time in this treatment setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24-hour setting and also to prevent possible life-threatening withdrawal symptoms or overdose. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time in this hospital. He required inpatient detoxification treatment prior to inpatient substance/alcohol rehabilitation treatment which he went to when discharged from the detoxification treatment. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance detoxification treatment as he was discharged to an inpatient substance rehabilitation treatment. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then.  

The insurer's denial of coverage for substance use inpatient detoxification is overturned. Medical Necessity is substantiated.