Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.

Treatment: 5 days/units of Inpatient Substance Abuse Services.

The insurer denied the5 days/units of inpatient substance abuse services.

The denial was reversed.

This is a female patient who was admitted to inpatient hospital treatment for detoxification. She reported having detoxification treatment in the past. The patient reported drinking large amounts of alcohol including 480 ounces of beer per day, $100 of crack/cocaine per day, and $10 of cannabis. The patient had withdrawal symptoms that included nausea, tremors, sweats, cravings, irritable mood, anxiety, sleeping problems, and yawning. The patient's toxicology was positive for cocaine, THC, and benzodiazepines. The patient had a high Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 17. She reportedly was unemployed and lacked a sober support system. The patient received and required detoxification medication including Librium as per protocol. The patient was stabilized and discharged to an 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 use of multiple substances daily in large amounts including alcohol, cocaine, and cannabis. Thus, the patient was at risk for severe, complicated, and life threatening withdrawal symptoms, and required inpatient medical hospital detoxification treatment.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required a 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 alcohol and cocaine daily despite past inpatient substance detoxification treatment. During this hospitalization, the patient needed detoxification of Librium to modify for her withdrawal symptoms from alcohol; the patient had a high Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 17 with active withdrawal symptoms. The patient was at high risk for even more severe, complicated, and life threatening withdrawal. The patient lacked a sober support system, lacked coping skills for abstinence, and had difficulty identifying triggers for use. The patient required 24-hour inpatient detoxification treatment due to the medical risk of life threatening withdrawal as well as her inability to maintain abstinence which required 24-hour detoxification treatment followed by 24-hour inpatient rehabilitation treatment. 

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 5 days/units of inpatient substance abuse services should be reversed. The medical necessity is substantiated.