Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Positive toxicology
Treatment: Inpatient detoxification level of care
The insurer denied coverage for: Inpatient detoxification level of care
The denial is : Overturned
This adult was admitted to this inpatient hospital for alcohol detoxification treatment. The patient had active withdrawal symptoms including tremors, nausea, abdominal pain, diarrhea, irritable mood, anxiety, and sleeping problems with a Clinical Institute Withdrawal Assessment (CIWA) of 14 and Clinical Opiate Withdrawal Scale (COWS) of 11. The patient reportedly was drinking up to 1 12 pints of liquor per day and five 24-ounce beers and using $50-$100 per day of cocaine. The patient had a positive toxicology for cocaine and Buprenorphine. The patient reportedly had no abstinent time and lacked coping skills for abstinence and lacked a sober support as the patient was homeless and unemployed. The patient had multiple past inpatient detoxification treatment and rehabilitation treatments and could not stop use. The patient was put on an Ativan protocol for detoxification treatment. The plan was for the patient to complete inpatient detoxification treatment and then be discharged to inpatient substance rehabilitation treatment. The patient was discharged 2 days later.
 
  
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 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 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) the patient did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily. The patient did require 24-hour inpatient medical hospital treatment for alcohol detoxification, and it was considered unsafe for him to be treated for detoxification in a less restrictive level of care. The patient was considered a high risk for relapse if not in this 24-hour inpatient hospital setting for detoxification treatment then and could not stop use despite so many past inpatient detoxification and rehabilitation treatments over the past several years.  The patient reportedly lacked coping skills and ability to identify relapse triggers for sobriety and lacked supports as the patient was homeless and unemployed. 

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 the admission to the substance use inpatient detoxification level of care is substantiated.