Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder

Treatment: Inpatient substance abuse treatment for 3 days/units

The insurer is denied coverage for inpatient substance abuse treatment for 3 days/units

The denial is reversed. 

This male was admitted to this inpatient hospital treatment for detoxification from alcohol, heroin, Xanax, cocaine and cannabis. He was reported to be using up to 40 bags of heroin per day, drinking 2 1/2 pints of liquor per day, 20 mg of Xanax 1-2 times per week, 4-6 blunts of cannabis per day, and 1/2 gram of cocaine IV 3-6 times per week. He had legal issues due to use including assault charges due to use. He reportedly was homeless. He reportedly had a positive toxicology for opiates, cocaine, benzodiazepines, THC, and methadone. He reportedly had multiple past inpatient substance detoxification treatments and also rehabilitation treatments including a detoxification treatment days prior to this admission. He reported that he feared he would overdose due to use and he reported withdrawal symptoms such as runny nose, teary eyes, and nausea. He reportedly was put on 2 detoxification medications including Librium and Methadone which he took from but he signed out AMA.

The 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. 

In this case this patient had use of large amounts of multiple serious substances of use and alcohol putting him at very high risk for overdose or severe, complicated, and life threatening withdrawal. He reportedly was using up to 40 bags of heroin per day, drinking 2 1/2 pints of liquor per day, 20 mg of Xanax 1-2 times per week, 4-6 blunts of cannabis per day, and 1/2 gram of cocaine IV 3-6 times per week.

According to the LOCADTR he 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 multiple serious substances of use and alcohol despite multiple past inpatient detoxification and rehabilitation treatments including a detoxification treatment several days prior to this admission and despite negative consequences including legal issues due to use. Also, he needed 2 detoxification medications (Librium and Methadone) to modify withdrawal and prevent severe, complicated, and life threatening withdrawal. He also lacked coping skills, ability to identify triggers, and he was homeless and did not have a sober support system as well. It was unlikely that he would remain abstinent outside of this hospital setting and he was a high risk for severe and life threatening withdrawal due to the large amount of serious substances of use and alcohol and also at high risk for overdose. His environment was not conducive to recovery as evidenced by his continued use. This was a high risk patient in need of hospital detoxification treatment. 

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

Based on the above, the medical necessity for the inpatient substance abuse treatment for 3 days/units is substantiated. The insurer's denial is reversed.