Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcer with Cellulitis and Maggots.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This patient was admitted to the hospital as she had an ulcer with cellulitis and maggots in her heel which needed debridement and was washed out.  She reportedly was put on intravenous (IV) antibiotics.  She reportedly was immunocompromised and had a past medical history of hepatitis C, asthma, endocarditis, and had a toe amputation.  She reportedly was using IV heroin and cocaine as well as alcohol.  She reportedly was non-compliant.  She reportedly was homeless. She reportedly was admitted to the surgery unit.  She also reportedly had a history of leaving hospitals prematurely and had past treatments.  She reportedly had opioid withdrawal symptoms and had a Clinical Opioid Withdrawal Score (COWS) of 4 and was treated for detoxification with Methadone while in the hospital and was discharged and walked to the methadone maintenance program escorted by the addiction counselors when discharged from the hospital. 

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.  It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

The US (United States) Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment , if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24-hour treatment, as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use multiple serious substances of use including IV heroin and cocaine with alcohol and was at risk for severe withdrawal and overdose.  She also had multiple serious medical issues including having an ulcer with cellulitis and maggots in her heel which needed debridement and was washed out, and she also had serious medical conditions including being immunocompromised, hepatitis C, asthma, endocarditis, had a toe amputation, and was at risk medically if not treated in this hospital setting.  She had acute medical issues, was homeless, lacked supports, had a history of noncompliance, and was considered unable to care for her needs if not in this hospital setting, as well. She did require 24-hour medical hospital detoxification treatment, and it was considered unsafe for her to have detoxification at a less restrictive level of care, as she was considered a high medical risk and at risk for worsened withdrawal.  She lacked coping skills and sober supports and could not be treated outside of a hospital setting, as she was at high risk for relapse and continued substance use and was unable to care for her medical needs. She required the staff to escort her to the methadone maintenance program by the addiction counselors when discharged from the hospital.  This was a high-risk patient in need of hospital treatment. 

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 admission is overturned.  Medical Necessity is substantiated.