Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse 

Treatment: Inpatient hospital admission at a substance abuse inpatient detoxification level of care

The insurer denied coverage for inpatient hospital admission at a substance abuse inpatient detoxification level of care

The denial is overturned

This male reportedly was admitted to this inpatient hospital. He reportedly had withdrawal symptoms including agitation, tremors, anxiety, tactile hallucinations, and had a COWS (Clinical Opiate Withdrawal Scale) of 12 and CIWA (Clinical Institute Withdrawal Assessment) of 8. He reportedly was drinking 2 pints of vodka per day and using 7 bags of heroin per day. He reportedly started using alcohol and heroin at an early age.  He reportedly was given 2 detoxification medications including Diazepam and Methadone. He reportedly lacked social supports and was unemployed. He reportedly denied any lengthy period of sobriety. It was reported that his addiction impaired his ability to commit to daily life necessities. He reportedly left AMA (against medical advice). 

The medical records provided enough specific evidence to support that he required this level of care then. The APA (American Psychiatry Association) 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 of alcohol daily including up to 2 pints of vodka per day and using up to 7 bags of heroin per day and could not stop use. According to the LOCADTR (Level of Care for alcohol and drug treatment referral) he did require 24-hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting as he continued to use large amounts of alcohol and heroin daily despite alcohol and heroin use contributing to impair his ability to commit to daily life necessities. He reportedly required and needed 2 detoxification medications to modify withdrawal, including Diazepam and Methadone for 5-day tapers and needed 24-hour inpatient hospital treatment then as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting then including severe and life-threatening withdrawal symptoms such as delirium tremens as well as overdose. He reportedly had active withdrawal symptoms including agitation, tremors, anxiety, tactile hallucinations, and had a COWS of 12 and CIWA of 8. He reportedly asked to leave AMA and lacked the coping skills to maintain abstinence or get detoxification treatment without this inpatient hospital detoxification treatment setting. It was unlikely that he would remain abstinent while still having withdrawal symptoms. He required the time in this treatment setting to stop withdrawals 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 4 days after alcohol use so he required the entire time in this hospital setting as he continued with detoxification medications of Diazepam and Methadone for 5-day tapers. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient alcohol detoxification in this hospital. 

It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission at a substance abuse inpatient detoxification level of care is overturned. Medical Necessity is substantiated.