Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance withdrawal.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.
 

This adult patient was brought in by ambulance to the emergency department (ED) due to being found unresponsive in her vehicle. She was given Narcan twice. She had altered mental status and was somnolent with no verbal response to pain and although she had some reported improvement in breathing, she was still somnolent. She reportedly was responding to internal stimuli. She had a positive toxicology report and was also drinking 5-6 pints of vodka per day. She reportedly had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 9 which increased to 14 and had withdrawal symptoms including tremors, nausea, agitation, anxiety, headache, and tactile disturbance. She reportedly was put on an Ativan CIWA protocol and Methadone protocol for detoxification treatment. She was given IV (intravenous) Solumedrol, thiamine, and folic acid. She had multiple past inpatient detoxification treatments. Medically she was immunocompromised, had a blood pressure of 149/89 and had prolonged QTc (interval on an electrocardiogram) with sinus bradycardia. She had elevated lipase and an anion gap of 6. She was on continuous cardiac monitoring and respiratory therapy. It was reported that she was admitted to the hospital floor and had a CIWA of 14 on day 3 and had tremors, agitation, and anxiety. She reportedly left against medical advice (AMA) despite strong recommendations to remain and treat her substance withdrawal and medical issues. 

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical records provided enough specific evidence to support that she required this level of care then. 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. Also, the 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. In this case this patient had active substance withdrawal symptoms including tremors, nausea, agitation, anxiety, headache, and tactile disturbance and had a CIWA as high as 14. She had an overdose of heroin and was unresponsive and needed Narcan. She was considered a very high risk for severe, complicated, and life-threatening withdrawal such as delirium tremens. 

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 inpatient admission is substantiated.