Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse.

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This male patient was admitted for inpatient hospital treatment for alcohol/substance rehabilitation/detoxification treatment.  The patient reportedly had withdrawal symptoms including sweats, tremors, diarrhea, joint pain, anxiety, sleeping problems, irritable mood, elevated heart rate of 105, and had a temperature of 99.  The patient reportedly was inhaling 1 bag of heroin per day and drinking alcohol daily and reported a 36-year history of use.  The patient toxicology was positive for opiates and benzodiazepines.  The patient's history was significant for multiple past inpatient detoxification treatments and rehabilitation treatment.  The patient reportedly lacked coping skills for abstinence and kept relapsing after discharge from past inpatient detoxification treatments and rehabilitation treatment.  The patient left against medical advice (AMA).

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, 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 US 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 an inpatient medical hospital as he reportedly was at risk for severe, complicated, and life-threatening withdrawal. The patient presented with active withdrawal symptoms. The patient also was at risk for overdose.  The risk of life-complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so this patient required inpatient detoxification treatment in this hospital prior to inpatient rehabilitation treatment.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use alcohol and heroin daily, and relapsed right after multiple past inpatient detoxification treatments and rehabilitation treatment in the past.  The patient needed 24-hour treatment then as he was at risk for worsening withdrawal symptoms if not in this 24-hour setting, such as delirium tremens. Due to this patient's high risk for life-threatening withdrawals and/or overdose, inpatient detoxification 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 the inpatient hospital admission should be reversed.  The medical necessity is substantiated.