Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This adult male patient was admitted to this inpatient hospital telemetry service for cardiac monitoring due to prolonged QTc (interval on EKG (electrocardiogram)) and bradycardia of 43. He went to the Emergency Department (ED) requesting detoxification treatment for heroin use. He reportedly was sniffing up to 20 bags per day of heroin and used 12 bags just prior to going to the ED. He had withdrawal symptoms including nausea, diarrhea, tremors, weakness, headache, nervousness, rhinorrhea, watery eyes, tremors, diaphoresis, and had a Clinical Opiate Withdrawal Scale (COWS) of 10 and a COWS of 14. He reportedly also smoked $150 of crack/cocaine and used cannabis. He was taking Klonopin prescribed by his outpatient physician. He had a positive toxicology for cocaine, cannabinoids, and benzodiazepines. He also had a past reported psychiatric hospitalization and had diagnoses of post-traumatic stress disorder (PTSD) in addition to opiate and cocaine use disorder. He was given detoxification medication for opioid withdrawal as he was given Methadone 30 milligrams (mg) and Methadone 20 mg. He also was prescribed Lorazepam for possible benzodiazepine withdrawal as he was taking Klonopin. He 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. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he reportedly needed detoxification medications to modify withdrawal and prevent more severe and possible complicated withdrawal. It was reported that he took Methadone 30 mg (milligrams) and Methadone 20 mg and also reportedly was prescribed Lorazepam for possible benzodiazepine withdrawal as he was taking Klonopin. He also had comorbid medical conditions complicating the management and treatment of withdrawal as he had prolonged QTc and bradycardia of 43 and required telemetry monitoring in an inpatient hospital setting also. His medical conditions and withdrawal symptoms in the context of using large amounts of heroin and cocaine put him at medical risk and he required 24-hour hospital treatment.  

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

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.