Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.
 
This adult patient was admitted to this inpatient substance detoxification treatment, as he reportedly had opiate and alcohol withdrawal symptoms including a Clinical Institute Withdrawal Assessment (CIWA) of 9 and Clinical Opiate Withdrawal Scale (COWS) of 14 on admission. He had diagnosis of Alcohol, Cocaine, and Opioid Use Disorder. He had a past heroin overdose 3 months prior to admission. He had a positive toxicology for cocaine, heroin, fentanyl, methadone, benzodiazepines, and THC (Tetrahydrocannabinol)/cannabis. He had a history of bipolar depression and hypertension. He was put on 2 detoxification medications including Valium and Methadone and still had withdrawal symptoms as his CIWA was 8-9 and COWS was 9-11 while taking these detoxification medications he left against medical advice (AMA).

The medical records provided enough specific evidence to support that he 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 use of multiple serious substances of use daily in large amounts including heroin, cocaine, and alcohol use.  He reportedly had a positive toxicology for cocaine, heroin, fentanyl, methadone, benzodiazepines, and THC/cannabis. He reportedly was  at risk for severe, complicated, and life-threatening withdrawal and overdose and required inpatient medical hospital detoxification treatment. 

According to the level of care for alcohol and drug treatment referral (LOCADTR), he did require 24-hour treatment, as he could not safely and effectively be treated for detoxification in a less restrictive setting, as he continued to use multiple serious substances of use despite multiple past treatment episodes, and he needed  2 detoxification medications, Methadone and Valium, to modify withdrawal from opioids and alcohol and prevent more severe, complicated, and life-threatening withdrawal. He still had reported withdrawal during detoxification treatment, as he had CIWA of 8-9 and COWS of 9-11, so he was at risk of severe, complicated, and life-threatening withdrawal if not in this setting getting detoxification treatment. He also was at risk medically of another overdose, as it was reported that he had a recent heroin overdose 3 months prior to admission. He also likely would have relapsed again, as evidenced by relapsing after multiple past treatment episodes. He reportedly left AMA (against medical advice) prior to completion of his detoxification treatment. He was considered a high risk medically, due to his large amount of using multiple serious substances of use and alcohol.  

Based on the above, the insurer's denial must be overturned. 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 inpatient hospital admission is substantiated.