Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid withdrawal symptoms
Treatment: Inpatient hospital detoxification treatment
The insurer denied coverage for: Inpatient hospital detoxification treatment
The denial is: Overturned
This adult patient was admitted to this inpatient hospital detoxification treatment. The patient had opioid withdrawal symptoms including tremors, yawning, anxiety, joint and bone aches, sweating, restlessness, runny nose, eye tearing, and had a Clinical Opiate Withdrawal Scale (COWS) of 12. The patient continued to experience withdrawal symptoms until discharge. The patient reportedly was using 15 bags of IV heroin per day and also using IV cocaine. The patient reportedly had an overdose 6 days prior to admission. The patient reportedly was buying Methadone off the street and using up to 80 milligram (mg) per day. The patient had a positive toxicology for opiates, Methadone, and cocaine. The patient had 4 unsuccessful past treatment episodes. It was reported that the patient was in this facility one month prior to admission, and also was in a Methadone Maintenance Program in the past. The patient also had comorbid post-traumatic stress disorder (PTSD) and depression with past suicidal ideation, and hepatitis C which was untreated. The patient reportedly had a hospitalization due to injuries from a physical altercation including needing 4 staples on his forehead. The patient reportedly was homeless and lacked sober supports. The patient was put on a Methadone taper for detoxification treatment. The patient initially wanted inpatient substance rehabilitation after completion of this inpatient substance detoxification treatment, but then wanted to be referred back to the past Methadone Maintenance program treatment upon discharge.


The reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment. The medical records provided enough specific evidence to support that the patient required 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. In this case this patient had been using large amounts of heroin daily including up to 15 bags of IV heroin per day and IV cocaine and had a recent overdose 6 days prior to admission which put him at high risk for another overdose and medical issues and death from overdose so the patient required 24 hour inpatient substance detoxification treatment. Also, the patient had active withdrawal symptoms including tremors, yawning, anxiety, joint and bone aches, sweating, restlessness, runny nose, eye tearing, and had a Clinical Opiate Withdrawal Scale (COWS) of 12 and required inpatient detoxification treatment. The patient also lacked coping skills and relapse prevention skills, ability to identify relapse triggers, motivation, and sober supports as he was homeless and unemployed. The patient continued to have withdrawal symptoms reported until discharge. The patient was at risk for death from overdose of heroin and also at risk for severe opioid withdrawal as well as medical consequences due to intravenous (IV) heroin and IV cocaine use. 
Based on the above, the insurer's denial must be reversed. 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 an inpatient detoxification admission is substantiated.