Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Admission

The insurer denied the inpatient admission. The denial was reversed. 

This is a female patient with a history of substance abuse. The patient reported using IV heroin, Xanax and Klonopin. She presented the Emergency Department (ED) with complaints of abdominal pain and tenderness. The patient's toxicology was positive for opiates and cannabinoids. Surgery and Gastroenterology consults were done. Laboratory work up was performed that revealed white blood cell (WBC) count 16.8, amylase 15, lipase <10; a pregnancy test was negative. Ultrasound of the abdomen was performed that showed contracted gallbladder with gallstones. Hepatobiliary scan was done that showed patent cystic and common bile ducts. The patient had intermittent episodes of nausea and vomiting. Intravenous (IV) fluids and antiemetics were administered. The patient received supplemented IV potassium for a low potassium level. The patient developed withdrawal symptoms that included tremors, nausea, vomiting, generalized aches, and anxiety; methadone and Ativan were administered. It was reported that the patient had an episode of unresponsiveness after having visitors to her room; there was suspicion of opiate overdose. Narcan was administered and the patient regained consciousness. The patient was placed on constant observation for safety. The patient signed out against medical advice (AMA). 

The 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 if comorbid medical conditions complicate the management of withdrawal, then inpatient hospital treatment is necessary. In this case this patient had used multiple substances including heroin, benzodiazepines, and cannabis and was using large amounts of intravenous (IV) heroin daily. This patient was thus, at a high risk for death from overdose. Furthermore, the patient was suspected overdose in the hospital after seeing her visitors as she was found unresponsive and was responsive to Narcan. This incident required the patient to be on constant observation, and at least 24-hour hospital treatment.

According to the LOCADTR criteria, the patient required 24-hour treatment as the patient could not safely and effectively be treated for detoxification in a less restrictive setting as the patient continued to use multiple serious substances of use despite negative consequences, and even had a likely overdose of opiates in the hospital requiring Narcan. During inpatient stay, the patient presented with withdrawal symptoms that required two detoxification medications, Methadone and Ativan to modify this patient's active withdrawal symptoms. The patient's long-term history of serious multiple substances use that included daily IV heroin, benzodiazepines off the street, and cannabis, indicated that this patient was at high risk for worsened withdrawal symptoms that could be life-threatening without a 24-hour inpatient level of care. The patient had comorbid medical conditions, gallstone and urinary tract infection, that complicated the management of this patient's substance withdrawal. This patient's incident of possible opiate overdose in the hospital also indicated that this patient was at high-risk for relapse, overdose death without constant observation in the inpatient setting. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.