Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse 

Treatment:  Inpatient detoxification treatment

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

This patient is a female was admitted from a substance rehabilitation treatment due to alcohol and substance detoxification.  She had withdrawal symptoms including tremors, nausea, abdominal pain, body aches, chills, irritable mood, agitation, altered mental status, lethargy, drowsiness, flushing, poor sleep, and had a CIWA of 9 and COWS of 10.  She reportedly was using 3 bundles of IV heroin, 4 grams of IV cocaine, drinking 1 pint and 4 beers daily, and using 5 tablets of Xanax per day.  She had a positive toxicology screen for opiates and cocaine. She reportedly had a prolonged QTc and had hepatitis C.  She had a history of blackouts.  She reportedly had comorbid depression, anxiety/PTSD and sleeping problems, as well as decreased appetite.  She had 3 past detoxification treatments.  She reportedly had medication non-compliance.  She was prescribed Abilify and Trazodone.  She was given IV Ativan and was put on a Librium protocol and Methadone protocol.  Inpatient substance rehabilitation treatment was advised, but she signed out AMA.

The insurer denied coverage for inpatient detoxification treatment stating that she did not have severe medical or mental health issues requiring 24 hour inpatient treatment.  They recommended a less restrictive level of care then.

The reviewer disagrees with the decision to deny coverage for inpatient detoxification treatment as the chart notes provided enough specific evidence to support that she required inpatient substance medical detoxification treatment then.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients who fail to achieve abstinence or patients who relapse frequently, or patients who fail to be cooperative with or benefit from outpatient detoxification, patients who have 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 was using large amounts of serious substances including using 3 bundles of IV heroin, 4 grams of IV cocaine, drinking 1 pint and 4 beers daily, and using 5 tablets of Xanax per day.  She was at high risk of overdose and severe, complicated, or life threatening withdrawal symptoms.  This patient had active alcohol withdrawal symptoms including tremors, nausea, abdominal pain, body aches, chills, irritable mood, agitation, altered mental status, lethargy, drowsiness, flushing, poor sleep, and she had a CIWA of 9 and COWS of 10, was receiving detoxification medications due to withdrawal, as it was reported that she took IV Ativan, and was put on a Librium protocol and Methadone protocol and even took Methadone.

According to the LOCADTR, she did require 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use alcohol, heroin, cocaine, and Xanax in large amounts daily and was considered a high risk for severe, life threatening, and complicated withdrawal, as well as overdose, and she needed multiple detoxification medications to modify withdrawal from alcohol, heroin, and Xanax, and she continued to drink large amounts of alcohol and use serious substances in large amounts daily, despite 3 past detoxification treatments, so she needed 24-hour treatment then, as she was at risk for worsened withdrawal symptoms if not in this 24-hour setting then, including possible life threatening withdrawal, such as delirium tremens (DT).

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.