Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid and Benzodiazepine Detoxification.

Treatment inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is overturned

This female was admitted to this inpatient hospital treatment after presenting in the Emergency Department (ED) for opioid and benzodiazepine detoxification. She had withdrawals symptoms including tremors, nausea, vomiting, mental fog, abdominal cramps, elevated heart rate of 136 and elevated blood pressure of 154/110, as well as tachypnea. The patient reportedly ran out of her 8 mg (milligrams) per day of Xanax, and it was reported that she might have had a seizure prior to this admission. She reportedly also was using Fentanyl, Vicodin, and Tramadol, not prescribed. The patient reportedly had outpatient substance treatment. She was given intravenous (IV) Ativan and IV fluid bolus and put on seizure precautions. The patient reportedly was living with her mother and boyfriend and was unemployed. She had psychiatry, pain management, and social work consults and psychiatry recommended changing from Xanax to Klonopin and she also took Seroquel. Pain management recommended Gabapentin and Flexeril. The patient was discharged.
    
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. 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 United States (US) 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. She continued to use multiple opiates and abruptly stopped a large amount of Xanax at 8 mg and had active withdrawal symptoms including tremors, nausea, vomiting, mental fog, abdominal cramps, elevated heart rate of 136 and elevated blood pressure of 154/110, as well as tachypnea, likely had a withdrawal seizure a few days prior to admission, was given IV Ativan for detoxification and to modify withdrawal from Xanax and then prescribed Ativan as needed. She was at risk for worsened withdrawal symptoms if not in this 24-hour setting including more severe, complicated, and even possible life-threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so she was considered at risk for this. She also was at risk for overdose as she was using large amounts of Xanax and multiple opiates daily including Fentanyl, Vicodin, and Tramadol, not prescribed. 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.

The inpatient hospital treatment was medically necessary. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient. The medical records provided enough specific evidence to support that she required this level of care.

The insurer's denial of coverage for the inpatient hospital stay is overturned. Medical necessity is substantiated.