Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Withdrawal symptoms. 
Treatment: Inpatient substance abuse treatment. 

The insurer is denied coverage for inpatient substance abuse treatment. 
The denial is overturned. 

This male patient has a history of anxiety and polysubstance abuse (opioids, sedatives, cocaine, and intravenous heroin).

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 condition that complicate the management of withdrawal are also candidates for inpatient detoxification. This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life threatening withdrawal due to large amounts of daily Xanax use, and also was using large amounts of IV(intravenous) heroin daily as well as cocaine so he was at risk for overdose again as well as worsened withdrawal. He reportedly had a past reported overdose one year prior to admission. He reportedly was put on a Methadone protocol taper and continued to have withdrawal symptoms until discharged. 

According to the 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 Xanax and heroin daily and also used cocaine and required and needed detoxification medication, Methadone, to modify withdrawal and prevent more severe, complicated, or life threatening withdrawal.  He was at risk for worsened withdrawal symptoms if not in this 24-hour setting then including severe and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-5 days after alcohol or benzodiazepine use so he required inpatient detoxification protocol treatment and was at risk medically and required 24-hour hospital treatment then. He continued to use multiple serious substances of use despite past legal problems and past overdose. He reportedly was homeless and unemployed and lacked supports for recovery. 

Notes reported worsened withdrawal with a COWS(Clinical Overviews Opioid Withdrawal) of 15 and he required continued Methadone detoxification treatment. Notes reported continued withdrawal with a COWS of 7 and he required continued Methadone detoxification treatment. Notes reported that he had continued withdrawal including joint aches, nasal congestion, stomach cramps, tremors, yawning, irritable mood and anxiety and had a COWS of 6 and he required continued Methadone detoxification treatment. Notes reported continued withdrawal including bone and joint aches, nasal congestion, stomach cramps, sleeping problems, anxiety and irritable mood, and tremors with a COWS of 5, and he required continued Methadone detoxification treatment. 

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 substance abuse treatment is overturned.  The medical necessity is substantiated.