Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Withdrawal symptoms Opioid Addiction
Treatment: Medically Supervised Inpatient Detoxification
The insurer denied coverage for: Medically Supervised Inpatient Detoxification
The denial is: Overturned
This adult patient was admitted to this inpatient hospital for detoxification treatment. The patient had withdrawal symptoms including tremors, sweats, agitation, anxiety, irritable mood, diffuse discomfort, cravings, dilated pupils, nasal stuffiness, elevated heart rate, and had a Clinical Institute Withdrawal Assessment (CIWA) of 9 and Clinical Opiate Withdrawal Scale (COWS) of 11. The patient had a positive toxicology for opiates, cocaine, Methadone, and tetrahydrocannabinol (THC). The patient reportedly was drink a six pack of 24 ounce beer per day, using 1 bag of heroin IV per day, and using $20 of cocaine IV per day. The patient was in Methadone Maintenance Treatment Program and unable to have any abstinence from alcohol and substances.  The patient continued to use multiple serious substances of use and alcohol daily despite 2 past inpatient detoxification treatments in the past. The patient lacked coping skills for abstinence and lacked sober supports as the patient was homeless and unemployed. The patient had comorbid medical and psychiatric issues including a past overdose of pills 10 years prior to admission and had past depression and psychiatric hospitalization. Past medical history included hepatitis C and asthma. The patient was put on a 5 day Librium taper but left against medical advice (AMA) prior to completion of the detoxification treatment. The plan was to complete inpatient detoxification treatment and then be referred for inpatient substance rehabilitation treatment.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that the patient required this level of care. 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. 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 United States (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. The risk of delirium tremens can occur 3-4 days after alcohol use so the patient was considered at risk for severe, complicated, and life threatening withdrawal and in need of 24 hour hospital treatment. According to the Level of Care for Alcohol and Drug Treatment Referral 
(LOCADTR) the patient did require 24 hour treatment as the patient could not safely and effectively be treated for detoxification in a less restrictive setting.
Based on above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Medically Supervised Inpatient Detoxification for dates of service is substantiated.