Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid withdrawal

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This adult reportedly was admitted to the hospital as he had reports of opioid withdrawal and medical issues including 3 days of vomiting dark colored, nausea, constipation, abdominal pain, increased heart rate of 134, elevated respiratory rate, dilated pupils, rhinorrhea, and a flushed face. He had minimal response to questions, low potassium (K), enteritis, and was being ruled out for bacteremia. He had a medical history significant for hypertension, fibromyalgia, peptic ulcer, gastroenteritis, and there was a sepsis work up. He was given intravenous (IV) Morphine and oral (po) Oxycodone for pain. He had electrolyte repletion and IV fluids, Zofran for nausea/vomiting, and was given zinc and thiamine. His diagnosis was opioid use with withdrawal, cellulitis, bacteremia, constipation, and gastroenteritis.
  
The medical records provided enough specific evidence to support that he required 24-hour hospital 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. 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 conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. Also, the 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. 

He was considered at risk of worsened opioid withdrawal symptoms or worsened medical issues as he had active withdrawal symptoms including 3 days of dark colored vomiting, nausea, abdominal pain, increased heart rate of 134, elevated respiratory rate, dilated pupils, rhinorrhea, flushed face, and he had minimal response to questions, enteritis, and was being ruled out for bacteremia, and there was a sepsis work up. He was considered too at risk medically to be treated in a less restrictive setting other than a hospital setting as he had acute medical issues with active opioid withdrawal putting him at risk medically and for worsened withdrawal as well as overdose. As a result, the recommendation is to overturn the previous decision and approve coverage for inpatient hospital treatment. 

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 the full hospital admission is substantiated.