Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder

Treatment: Inpatient substance detoxification

The insurer has denied coverage for Inpatient substance detoxification. The denial was reversed.

This male patient was admitted to this inpatient substance detoxification treatment after presenting to the ER for alcohol and substance detoxification treatment. He reportedly had withdrawal symptoms including tremors, joint pain, and lower extremity discomfort as well as a positive toxicology for substances with a blood alcohol level of 0.71. The patient was reportedly drinking a significant amount of alcohol, opiates, and street substances daily. He had 25 past detoxification treatments, 3 past inpatient rehabilitation treatments, and 2 past outpatient substance treatments. He was treated with two detoxification medications including Librium and Methadone. He reportedly was homeless and lacked coping skills or sober supports, and was hustling money for drugs. The patient was discharged with the recommendation to return to the Methadone Maintenance Program and the substance treatment center.

The insurer denied coverage for inpatient substance detoxification treatment as not medically necessary treatment. They stated that there were no medical or mental health issues requiring 24 hour detoxification treatment, and they recommended a less restrictive level of care then.

This reviewer disagrees with the decision to deny coverage for the inpatient substance detoxification treatment as the chart notes provided enough specific evidence to support that he needed this treatment. 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 multiple substances including street substances and alcohol, and was at risk for death from overdose, and at risk for severe, complicated, and life threatening withdrawal. According to the 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 substances despite multiple past inpatient treatments including 25 past detoxification treatments, 3 past inpatient rehabilitation treatments, and 2 past outpatient substance treatments, and he needed two detoxification medications to modify withdrawal including Librium and Methadone. He was reportedly homeless and did not have a sober support system and lacked coping skills. It was unlikely that he would remain abstinent while having withdrawal symptoms also so he required the time in this treatment setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24 hour setting.

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is substantiated.  The insurer's denial is reversed.