Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use
 
Treatment: inpatient substance detoxification treatment

The insurer denied coverage for inpatient substance detoxification treatment. The denial was reversed.

This patient is a male was admitted to inpatient substance detoxification treatment for substance detoxification. He had withdrawal symptoms including sweats, tremors, restlessness, dilated pupils, mild diffuse discomfort, nasal stuffiness, stomach cramps, heart rate greater than 80, anxiety, and had a Clinical Opiate Withdrawal Scale (COWS) of 15.  He was using 2-5 bags of heroin per day intravenous (IV), $10 per day of IV cocaine 3-6 days per week, and smoking cannabis daily since teen years. He lacked sober supports and had limited family support, and was unable to remain sober on his own.  He reportedly had multiple past inpatient substance detoxification treatments including mid and late- 2018. He was put on a Methadone protocol and was discharged.

The insurer denied coverage for inpatient substance detoxification treatment as not medically necessary treatment then.  They stated that there were no acute psychiatric or medical issues, or life threatening withdrawal symptoms.  They stated that he did not require 24 hour inpatient substance detoxification treatment then, and they recommended a less restrictive level of care then.

This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment. 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 report 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 use of multiple substances including heroin, cocaine, and cannabis and was at risk for death from overdose as a result.  

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 for detoxification in a less restrictive setting as he continued to use multiple serious substances despite multiple past inpatient treatments as he had multiple past inpatient substance detoxification treatments.  Also, he needed detoxification medication to modify withdrawal as he was on a Methadone protocol during the denial period, had long term multiple substances of use including using heroin, cocaine, and cannabis, and he needed 24 hour treatment then as he was at risk for worsened and severe withdrawal symptoms if not in this 24 hour setting then, and he likely would have relapsed again as evidenced by relapsing after past treatments.  

Inpatient substance detoxification was medically necessary.  It did not appear that the health care plan acted reasonably or in the best interests of the patient.

The carrier's denial of coverage for the inpatient detoxification hospital admission is reversed.  The medical necessity is substantiated.