Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient detoxification admission

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

This patient is a male was admitted to this inpatient substance detoxification treatment due to alcohol and opiate detoxification. He reportedly had a CIWA of 10 and had reports of withdrawal symptoms including tremors, diaphoresis, nausea, vomiting, anxiety and insomnia. He was drinking several 24 ounce beers daily and had alcohol use since adolescence. He was using cannabis and benzodiazepines. He had 2 past inpatient substance detoxification and inpatient substance rehabilitation treatment and left the rehabilitation treatment and relapsed. He was homeless. He was put on an Ativan taper and Methadone maintenance; he was discharged.

The insurer denied coverage for inpatient substance detoxification treatment. This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment as the chart notes did provide enough specific evidence to support that he needed this level of care. The 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. In this case this patient had been drinking large amounts daily including drinking 8-10 24 ounce beers daily. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated in the outpatient detoxification setting as he continued to use alcohol daily despite reports that he failed previous outpatient treatment for recovery and 2 past inpatient substance detoxification and rehabilitation treatments including leaving a rehabilitation treatment and then relapsing so he needed more inpatient substance detoxification treatment then. He also required and needed detoxification medications including an Ativan taper and protocol then to modify withdrawal and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms including severe, complicated or life threatening withdrawal if not in this 24 hour setting then. He also took Methadone for maintenance to prevent a relapse with heroin as he had a history of past use months prior to admission.

He likely would have relapsed again as evidenced by relapsing after past treatments including 24 hour treatment. Also, he was reportedly homeless and lacked sober supports.  It was unlikely that he would remain abstinent while having withdrawal symptoms so he required the admission and remaining time in this treatment setting to stop withdrawals and prevent more serious withdrawal including possible life threatening withdrawal and decrease the chance that he would relapse again when not in this 24 hour setting.  The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required the entire time.

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

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