Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: 2 days/units of Inpatient Substance Abuse Services
The insurer is denied coverage for 2 days/units of Inpatient Substance Abuse Services.
The denial is overturned. 

This is a male patient who was admitted to the hospital for opioid detoxification. The patient reportedly had acute withdrawal symptoms including sweats/chills, tremors, nausea, abdominal pain, diarrhea, muscle cramps, malaise, fatigue, watery eyes, anxiety, and irritable mood. The patient reportedly was using up to 20 bags of intravenous (IV) heroin per day and also using methadone off the street at times. The patient had a positive toxicology for opiates and methadone. The patient reportedly had multiple past inpatient substance detoxification treatments and rehabilitation treatments. The patient reportedly was homeless and unemployed. The patient's had a medical history of liver disease. His Clinical Opiate Withdrawal Scale (COWS) score was reported to be 8. The patient was treated with Methadone taper and protocol. The patient 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. This was the case with this patient. This patient had multiple past substance detoxification treatments and rehabilitation treatments including 10 detoxifications, 5 rehabilitations and 1 residential treatment in the past. Despite these multiple treatment history, the patient still relapsed and could not stop use. It was reported that the patient would do anything and go to any extent to obtain heroin. It was not likely that the patient could attend a less restrictive level of care than an inpatient substance detoxification treatment. The patient also was at risk for accidental overdose as well as severe withdrawal as he had acute, active withdrawal symptoms on admission and during the denial period. Notes reported that the patient exhibited continued withdrawal symptoms including chills, red and watery eyes, and bone pain; the patient was treated with Methadone for detoxification. Notes reported that the patient was still taking Methadone for withdrawal but he left against medical advice (AMA).

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as the patient needed detoxification medications to modify his withdrawal and had a history of heavy intravenous (IV) heroin use putting him at high risk for overdose and severe withdrawal. The patient also had multiple past inpatient treatments and continued to use heroin despite the negative consequences to his use including negative relational issues and medical issues including hepatitis C infection. The patient also lacked sober supports, was homeless, and unemployed. It was also reported that the patient had a high tolerance which put him more at risk for life-threatening overdose and/or withdrawal. Thus, inpatient detoxification was medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the 2 days/units of Inpatient Substance Abuse Services should be overturned. The medical necessity is substantiated.