Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Withdrawal Seizure. 
Treatment:  Continued Substance Use Disorder Services.

The insurer denied coverage for continued Substance Use Disorder Services.  The denial is reversed. 

This patient is a male admitted to residential substance use treatment after a reported hospitalization due to a withdrawal seizure.  It was reported that the patient's seizure was related to his withdrawal, and his Clinical Institute Withdrawal Assessment (CIWA) score was 10.  The patient was also noted to have withdrawal symptoms including headache, body aches, restlessness, tremors, insomnia, and anxiety.  The patient was treated with Librium for detoxification and had completed treatment.  The patient then had substance rehabilitation treatment but then had another withdrawal seizure and required Librium for breakthrough treatment and an Emergency Department (ED) evaluation.  When the patient returned to the facility, he was started on Keppra to prevent seizure.  The patient's substance use history included drinking up to 12 drinks per day with regular use of alcohol since early adulthood and first use as a child, using up to 4 mg of Xanax per day, and smoking heavy amount of cannabis, also.  The patient refused past substance treatment.  The patient had suicidal and homicidal ideation while in rehabilitation treatment, as well as purging behavior, and was not reported at his baseline function and health status. 

The American Psychiatry 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 reports that patients with past withdrawal seizures or delirium tremens are in need of 24-hour inpatient detoxification.  In this case, this patient met the APA recommendation for 24-hour inpatient/residential detoxification. 
 
According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment, as he needed detoxification medication and received detoxification medication of Librium on a specified date, as he had another reported withdrawal seizure and was at high risk for delirium tremens and life threatening withdrawal.  The patient required multiple detoxification treatments with Librium, initially and then again after his withdrawal seizure that required Emergency Department (ED) evaluation and addition of Keppra to his medication regimen. 

The American Psychiatry Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  In this case this patient was considered in need of 24-hour substance rehabilitation treatment.  Also, the National Institute on Drug Abuse: Principles of Addiction Treatment: A Research Based Guide- reports that the best treatment outcomes occur with longer durations of treatment.  It also states that recovery from drug addiction is a long term process and that treatment techniques to increase motivation for treatment are necessary to prevent dropout rates.  In this case, this patient required this 24-hour residential substance detoxification and rehabilitation treatment. 

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 continued Substance Use Disorder Services is reversed.  The medical necessity is substantiated.