Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polysubstance abuse

Treatment: Substance use-inpatient detoxification

The insurer denied coverage for substance use-inpatient detoxification

The denial is overturned

This patient was admitted to this inpatient substance detoxification treatment for detoxification treatment. He had withdrawal symptoms. He reportedly was drinking 1 pint of liquor per day and up to two six packs of beer per day. He reportedly also was using $100 worth of cocaine 1-2 times per week and smoking $10 worth of cannabis per day. He reportedly had multiple past treatment episodes including inpatient substance detoxification treatments and an inpatient substance rehabilitation treatment. He reportedly was homeless. He was started on a Librium protocol and given Librium twice per day. He reportedly left against medical advice (AMA) and also took Librium once on that day and did not follow up on the recommendation to complete the detoxification and then go to inpatient substance 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 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 pint of liquor and two six packs of beer daily and could not stop use. 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 in a less restrictive treatment setting as he continued to use large amounts of alcohol daily and daily cocaine use despite multiple past inpatient treatments including 2 detoxification and one rehabilitation treatment. He also required and needed detoxification medications to modify withdrawal, including Librium, and needed 24-hour inpatient hospital treatment as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting then including severe and life-threatening withdrawal symptoms such as delirium tremens. He reportedly had active withdrawal symptoms including hot and cold sweats, tremors, nausea, anxiety, cravings, irritable mood, headache, and pain with a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 9 and was at risk for severe, complicated, or life-threatening withdrawal. He reportedly could not maintain abstinence and lacked supports as he was homeless and lacked coping skills and ability to identify relapse triggers, so he could not be treated outside of a 24-hour setting. 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 24-hour inpatient detoxification treatment setting. The plan was for him to complete this inpatient detoxification treatment and then attend inpatient rehabilitation treatment, but he left AMA. 
    
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 substance use-inpatient detoxification is overturned. Medical Necessity is substantiated.