Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Detoxification
 
Treatment: Inpatient Substance Abuse Services

The insurer denied the Inpatient Substance Abuse Services. The denial was reversed.

This is a male patient was admitted to this inpatient substance detoxification treatment in the beginning of 2019 for substance and alcohol detoxification.  He had withdrawal symptoms including nausea and vomiting, sweating, joint pain, irritable mood, anxiety, yawning, and sleeping problems. He had a Clinical Opiate Withdrawal Scale (COWS) score of 8 and a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 7.  He was heavily using substances. He had multiple past inpatient substance detoxification and rehabilitation treatments.  He had an infectious disease.  He was homeless, had no family support, and lacked a sober support system. He also lacked coping skills to maintain abstinence.  He had medical issues, including a low hemoglobin (HB) of 12.3 and hematocrit (HCT) of 36.9, poor dentition, and tracks marks on his arms.  He also had legal issues. He started two detoxification medications to modify withdrawal including Librium and Methadone during this admission and he was discharged. He was transferred to inpatient substance rehabilitation 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.  In this case, this patient had been using multiple serious substances in large amounts; therefore, he was at high risk for overdose, as well as moderate to severe withdrawal symptoms. As such, he required inpatient substance detoxification treatment.  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 in outpatient detoxification settings. This was evidenced by the fact that he continued to use substances despite past multiple inpatient detoxification and rehabilitation treatments. He required two detoxification medications, including Librium and Methadone during this admission for substance and alcohol detoxification treatment.  He was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including severe and life-threatening withdrawal symptoms.  The risk of life-threatening and complicated withdrawal such as delirium tremens can occur three to four days after alcohol or benzodiazepine use; therefore, he required this inpatient substance detoxification treatment. Additionally, he required inpatient detoxification treatment prior to inpatient substance rehabilitation treatment.  He continued to use multiple serious substances despite negative consequences, including legal problems and arrests, in addition to medical problems, including an infectious disease, poor dentition, track marks, and anemia.  He also lacked coping skills and the ability to identify relapse triggers, and he had co-morbid psychiatric issues including Attention Deficit Hyperactivity Disorder (ADHD). He was homeless, had no family support, and lacked a sober support system. He could not maintain abstinence and was at risk for worsened withdrawal.  He required 24-hour inpatient hospital detoxification treatment.

The carrier's denial of coverage for the inpatient substance abuse services is reversed.  The medical necessity is substantiated.