Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse 

Treatment: Inpatient substance abuse treatment

The insurer denied coverage for inpatient substance abuse treatment. The denial reversed.

This patient is a male who reportedly was admitted to this inpatient substance detoxification treatment due to heroin detoxification.  He reportedly had anxiety and insomnia.  He had four past inpatient substance detoxification treatments, two past inpatient substance rehabilitation treatments, and one past substance outpatient treatment and could not stop heroin use.  He reportedly was using 8-10 bags per day of intranasal heroin.  He reportedly had past vomiting, tremors, and lightheadedness.  He reportedly was put on a Methadone protocol and took Methadone for detoxification for a specified number of days. He reportedly left against medical advice (AMA). 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 required this level of treatment then.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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.  This was the case with this patient.  This patient had four past inpatient substance detoxification treatments and two past inpatient substance rehabilitation treatments, and one past substance outpatient treatment and could not stop heroin use as he was still using large amounts of heroin daily.  It was reported that he needed better coping skills and identification of relapse triggers and could not stop heroin use without a 24 hour treatment so he could not safely and effectively be treated for detoxification in an outpatient setting.  It was not likely that he could attend an outpatient substance detoxification treatment due to his continued use despite past inpatient substance treatments so he required only inpatient substance detoxification treatment then.  He also was at risk for accidental overdose.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he needed detoxification medication, Methadone, to modify withdrawal and could not stop heroin use despite multiple past treatments so outpatient treatment for detoxification was not considered enough or safe as he needed 24 hour treatment for detoxification. 

As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient acute hospital treatment for substance detoxification treatment as he was reportedly left AMA after his Methadone dose. It did not appear that the health care plan acted reasonably or in the best interests of the patient then.  

The carrier's denial of coverage for inpatient substance abuse treatment is reversed.  The medical necessity is substantiated