Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient detoxification admission

The insurer has denied coverage for inpatient detoxification admission

The denial is overturned. 

This male patient was admitted for inpatient detoxification treatment from alcohol, Xanax, and heroin.  The patient reportedly had past withdrawal seizure, and had current active withdrawal symptoms including body aches, nausea, hot and chills, anxiety, and insomnia. The patient reported having a relapse 1 month ago and was drinking alcohol, and using Xanax and heroin. The patient had inpatient detoxification treatment in the past. The patient was admitted and was treated with phenobarbital and methadone protocol, and remained on the methadone protocol until the day of discharge.

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.  Also, the United States 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 past reported alcohol withdrawal seizures which required inpatient medical detoxification treatment and was in current withdrawal from three different substances (i.e. alcohol, Xanax, and heroin) and was at risk for severe, complicated, and life threatening withdrawal as well as overdose.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient required 24-hour treatment as he could not have been safely and effectively treated for detoxification in a less restrictive setting as he continued to use alcohol, Xanax, and heroin daily, and required and received two detoxification medications (i.e. phenobarbital and methadone) to modify  this patient's active withdrawal symptoms from alcohol, Xanax, and heroin and prevent another withdrawal seizure, such as delirium tremens. The patient was a high risk for relapse and overdose, as this patient has been continuing the use of several serious substances despite past inpatient detoxification treatment. During admission, notes indicated that the patient continued with detoxification protocol for alcohol, benzodiazepines, and heroin. The patient still had withdrawal symptoms, including myalgia and diaphoresis and continued with the methadone and phenobarbital protocol.  It was reported that he needed stabilization with methadone dosage prior to rehabilitation treatment. The patient required and received detoxification treatment until discharge. Thus, inpatient hospital admission was medically necessary for this patient.

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 inpatient substance abuse admission should be reversed. The medical necessity is substantiated.