Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse 
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission. 
The denial is overturned. 

This adult patient was admitted to this inpatient hospital setting for detoxification treatment. She reportedly had withdrawal symptoms including tremors, nausea, visual hallucinations, anxiety, agitation, irritable mood, and was somnolent. She reportedly was using one bundle of heroin daily by smoking it and also using intravenous (IV) methamphetamine, and also using cocaine. She reportedly last used heroin the morning of admission. She reportedly had a Clinical Opiate Withdrawal Scale (COWS) of 14 and Clinical Institute Withdrawal Assessment (CIWA)  of 15. She reportedly was given buprenorphine and Diazepam and also prescribed Clonidine and Oxazepam as needed. She reportedly completed the detoxification and was discharged with an appointment for inpatient substance rehabilitation treatment. 

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment. They stated that she did not have signs of withdrawal that was high risk requiring inpatient admission, did not have a history of withdrawal seizures, severe vomiting/diarrhea or severe abnormal bloodwork, or a heart rate over 120 or temperature over 101. They recommended a less restrictive level of care. 

The medical records provided enough specific evidence to support that she needed this level of care. 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. Also, the US (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 could not safely be treated in a less restrictive setting than inpatient medical hospital as she reportedly was using large amounts of serious substances of use including heroin, methamphetamine, and cocaine which put her at risk medically and also for overdose as well as severe withdrawal. She reportedly had withdrawal symptoms including tremors, nausea, visual hallucinations, anxiety, agitation, irritable mood, and was somnolent and had a COWS of 14 and CIWA of 15. She reportedly was using one bundle of heroin daily by smoking it and also using IV methamphetamine, and also using cocaine. It was not likely that she could attend an outpatient substance detoxification treatment due to her continued use of multiple substances of serious use so she required this  inpatient substance detoxification treatment. 

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 the hospital admission Hospital is substantiated.