Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient chemical dependency detoxification admission
The insurer is denied coverage for inpatient chemical dependency detoxification admission. The denial is overturned.

This patient is a male who was admitted for inpatient detoxification treatment. The patient reportedly had withdrawal symptoms including nausea, vomiting, tremors, urges, sleeping problems, teary eyes, sweats, irritable mood, anxiety, lightheadedness, and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 15. The patient reportedly was drinking 1 pint of vodka per day and 6 16 ounce beers, using bags of intranasal heroin per day, and also using crack/cocaine per day. The patient also had a history of alcohol use, history of heroin use, and history of cocaine use. The patient reportedly was using methadone. The patient reported multiple inpatient detoxification treatments and rehabilitation treatments with the most recent one. The patient was noted to be unemployed, and had a positive toxicology for opiates, cocaine, methadone, and benzodiazepines. The patient was admitted and was treated with Librium protocol. The patient was on the Librium protocol and also was treated with methadone protocol; the patient's last methadone protocol was on the day of discharge. The patient was discharged to a substance inpatient rehabilitation 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 treatment at a less restrictive level of care, 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 co-morbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as the patient could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol, heroin, crack/cocaine daily, and methadone despite multiple past inpatient detoxification and inpatient substance rehabilitation treatments. Also, the patient required two detoxification medication protocols while admitted to modify his withdrawal symptoms from alcohol and heroin. The patient had active reported withdrawal symptoms including nausea, vomiting, tremors, urges, sleeping problems, teary eyes, sweats, irritable mood, anxiety, lightheadedness, and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 15 at the time of admission. The patient needed 24-hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting, such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so this patient was considered at risk for this life-threatening withdrawal complication. The patient was also at risk for overdose as he was using large amounts of alcohol with heroin and crack/cocaine daily.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient chemical dependency detoxification admission should be overturned. The medical necessity is substantiated.