Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment inpatient substance abuse detoxification

The insurer denied coverage for inpatient substance abuse detoxification

The denial is overturned

This patient was admitted to inpatient detoxification treatment. He reportedly had active opioid withdrawal symptoms including joint/bone discomfort, chills/flushing, anxiety, irritable mood, piloerection, weakness, body aches and pain, tremors, restlessness, and he had a Clinical Opioid withdrawal score (COWS) of 14. He was reportedly using 8-9 bags of IV (intravenous) heroin per day with last use the day prior to admission and he had started use as an early age. He reportedly also was using street Methadone. He reported that he wanted to stop hurting but could not maintain abstinence on his own as his longest reported abstinence was 1 12 months. He continued to use heroin and Methadone despite multiple past inpatient substance detoxification treatments. He also had comorbid depression and anxiety and had a history of a gunshot wound to the chest. He took Methadone for detoxification including 30 mg (milligrams) of Methadone and 25 mg of Methadone following day and he was on a taper too. He reportedly left against medical advice (AMA) stating that he could not take the hurt as his body hurt despite the strong recommendation to continue his detoxification treatment. 
  
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. This was the case with this patient. This patient had reports of past inpatient substance detoxification treatments and still was using large amounts of IV heroin daily and street Methadone which put him at risk for overdose and severe withdrawal symptoms. It was reported that he did not have the appropriate coping skills to maintain abstinence. It was not likely that he could attend an outpatient substance detoxification treatment due to his continued use despite past inpatient substance treatments and active withdrawal symptoms including joint/bone discomfort, chills/flushing, anxiety, irritable mood, piloerection, weakness, body aches and pain, tremors, restlessness, and he had a COWS of 14. Further evidence of this was that he left AMA prior to the completion of his detoxification treatment scheduled as he left AMA stating that he could not take the hurt and pain due to withdrawal. He reportedly left despite strong recommendations by the staff for him to continue and complete his detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he needed detoxification medication to modify withdrawal and had a long history of heavy IV heroin use putting him at high risk for overdose and needing 24 hour treatment due to this risk and also the risk of more severe withdrawal. He continued to report withdrawal symptoms and even including body aches and muscles hurting. He reportedly had multiple past inpatient detoxification treatments and continued to use large amounts of daily IV heroin so treatment for detoxification at a less restrictive level of care was not considered enough or safe as he needed 24 hour inpatient treatment at this facility for detoxification. He also had comorbid depression and anxiety and a past gunshot wound to the chest. He was considered a high-risk patient in need of inpatient substance detoxification treatment in this facility including days denied by insurer. 

Inpatient acute hospital treatment for substance detoxification treatment 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 substance abuse detoxification is substantiated. The insurer's denial is overturned.