Appeal type: Medical necessity
Decision: Overturned

Diagnosis Substance Use Disorders

Treatment Inpatient substance detoxification and rehabilitation treatment

The insurer denied coverage for Inpatient substance detoxification and rehabilitation treatment

The denial is Overturned

 
This adult male reportedly was admitted to this inpatient substance rehabilitation treatment as he reportedly was drinking 3-4 bottles of liquor per day with a 35-year history of use, snorting 1 bundle of cocaine daily, and also smoking cannabis. He reportedly had a past hospitalization 9 months prior to admission due to substance use. He reportedly could not stop substance and alcohol use without being in a 24-hour inpatient setting as it was reported that in the homeless shelter that there was substance and alcohol use. He reportedly lacked coping skills and a supportive sober system for abstinence. His urine toxicology were reportedly positive when tested in the shelter. He reportedly had a positive toxicology for cocaine and THC. He reportedly left against medical advice (AMA) despite recommendations to remain and complete his treatment.

The insurer denied coverage for inpatient substance detoxification and rehabilitation treatment as not medically necessary treatment. They stated that he was not at risk of life-threatening withdrawal, did not have acute physical or psychiatric comorbid conditions requiring 24-hour inpatient rehabilitation or detoxication treatment, did not have suicidal or homicidal thoughts or psychotic symptoms, and was able to care for his basic needs. They recommended a less restrictive level of care.

The reviewer disagrees with the decision to deny coverage for inpatient substance detoxification and rehabilitation treatment as the medical records provided enough specific evidence to support that he required inpatient substance detoxification and rehabilitation treatment. The American Psychological Association (APA) Practice Guidelines for the treatment of patients with substance use disorders (SUD) 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. The patient was at risk for serious medical problems, overdose, and severe, complicated or life-threatening withdrawal so he required inpatient substance detoxification and rehabilitation treatment. According to the Level of Care Determination (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated for detoxification or rehabilitation in a less restrictive setting as he continued to use very large amounts of alcohol daily and cocaine despite past inpatient substance treatment. The risk of delirium tremens can occur 3 - 4 days after heavy alcohol use so he was considered at risk for this and in need of 24-hour inpatient detoxification and rehabilitation treatment. The patient was considered a high risk for relapse without 24-hour therapeutic inpatient substance/alcohol rehabilitation treatment also. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance detoxification and rehabilitation treatment.
Based on the above, the insurer's denial must be overturned. 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 the admission at a substance abuse inpatient detoxification level of care is substantiated.