Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a female patient who was admitted to inpatient hospital treatment as she was requesting detoxification from heroin and benzodiazepines.  She reportedly was admitted to telemetry due to possible Wolff Parkinson White syndrome and was at risk for tachyarrhythmia.  She reportedly had withdrawal symptoms including muscle cramps, runny nose, hot and cold flashes, sweats, restlessness, lethargy, headache, yawning, irritable mood, and heart rate of 96.  She reportedly had been using 5-10 bags of heroin and used to use intravenous (IV) but reportedly was sniffing a bundle of heroin daily and also using 5-10 tablets of prescribed Alprazolam instead of taking 3 times per day.  She reportedly had past inpatient substance detoxification treatment.  She reportedly had a history of depression and anxiety.  She also reportedly had hypothyroidism.  She reportedly lived by herself.  She reportedly was put on an Ativan 2 milligrams (mg) every 6 hours as needed detoxification protocol and also given Methadone.  She reportedly was seen initially in telemetry as she was admitted to telemetry due to possible Wolff Parkinson White syndrome and was at risk for tachyarrhythmia.  She reportedly left Against Medical Advice (AMA). 

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.  

The 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. 

In this case this patient could not safely be treated in a less restrictive setting than inpatient medical hospital, as she reportedly had active withdrawal symptoms and was using large amounts of heroin and Alprazolam and also had serious medical issues complicating the management of withdrawal.  She reportedly was admitted to telemetry due to possible Wolff Parkinson White syndrome and was at risk for tachyarrhythmia.  This patient had use of multiple substances including heroin, Alprazolam, and cannabis and was at risk for death from overdose as well as more severe and even complicated or life threatening withdrawal such as delirium tremens. 

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 large amounts of serious substances of use despite past inpatient substance detoxification treatments, needed detoxification medications to modify withdrawal for heroin and benzodiazepines, had long term multiple substances of use including using heroin, Alprazolam, and cannabis. It did not appear that she could be safely or successfully detoxified in a less restrictive setting than inpatient hospital treatment. 

It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then.

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