Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heroin overdose
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Reversed
This patient was admitted to the inpatient hospital after reportedly taking 40 milligram (mg) of heroin intravenous (IV) possibly laced with an unknown substance. The record reported withdrawal symptoms including diarrhea, tremors, and shortness of breath (SOB). The patient had a history of a withdrawal seizure. There was suspicion of pneumonia and fluid overload. The patient had anemia and a history of a duodenal ulcer. The patient was homeless. It was reported that the patient was using IV heroin and drinking 5 pints of vodka daily. The patient had 13 Emergency Department (ED) visits in the past 2 months and most recently for alcohol withdrawal. The patient was also buying Suboxone off the street. The patient was put on Librium for Clinical Institute Withdrawal Assessment (CIWA) protocol and given IV antibiotics and ferrous sulfate for anemia. The patient took Librium for detoxification but then left against medical advice (AMA). 
  
This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment from as the medical records provided enough specific evidence to support that the patient 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. It also states that patients with past or current 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. 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 or current withdrawal seizures or delirium tremens, or if one does not have the capacity for informed consent. The patient was considered at high risk for life threatening withdrawal and in need of 24-hour hospital treatment then. Also, the patient was at risk for another overdose. The patient lacked supports as he was homeless and reportedly had past hospital and ED visits recently prior to admission including for alcohol detoxification. 

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. The patient also was considered a high risk for relapse if not in this 24-hour inpatient hospital setting for detoxification treatment and also had comorbid medical issues. 

Based on the above, the insurer's denial must be reversed. 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 an inpatient admission to is substantiated.