Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance withdrawal
Treatment: inpatient detoxification level of care
The insurer denied coverage for inpatient detoxification level of care.
The denial is overturned.

This adult patient was admitted to this inpatient substance rehabilitation treatment for substance detoxification and rehabilitation treatment. The patient reportedly was smoking $100 worth of cocaine daily. It was reported that the patient was unable to remain abstinent on their own and lacked the coping skills to remain sober. The patient reportedly grew up in an environment with drugs and alcohol daily. The patient was at risk for medical complications due to the large amount of cocaine use and also at risk for cocaine withdrawal. The plan was to complete detoxification at this inpatient substance rehabilitation treatment and then be transferred to an inpatient substance residential treatment to complete the substance rehabilitation treatment. The patient was discharged and transferred to an inpatient substance residential treatment.
  
This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification and rehabilitation treatment at this facility. The patient was discharged and transferred to an inpatient substance residential treatment and the medical records provided enough specific evidence to support that the patient required this level of care. 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, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. The United States Department of Health and Human Services-Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment reports that inpatient treatment is necessary if the ability to attend outpatient treatment daily is a problem, one is unable to follow up in outpatient treatment , if medical conditions complicate the treatment of withdrawal, if one has previous withdrawal seizures of delirium tremens, or if one does not have the capacity for informed consent. In this case this patient could not safely be treated in a less restrictive setting than an inpatient detoxification/rehabilitation setting as the patient reportedly was at risk for cocaine intoxication or cocaine withdrawal due to the large amount of cocaine use daily. The patient was at risk for cardiac problems including myocardial infarction or even strokes, elevated blood pressure or heart rate, or cardiac arrhythmias as well as psychosis or mania. The patient was at risk for cocaine withdrawal including depression and decreased psychomotor activity. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient met criteria for inpatient substance rehabilitation treatment as the patient continued to use large amounts of cocaine daily putting the patient at high risk medically and psychiatrically for cocaine withdrawal depression. The patient lacked the sober supports, coping skills, relapse prevention skills, ability to identify relapse triggers, insight, or motivation to be treated outside of a 24-hour inpatient rehabilitation treatment setting for both detoxification and rehabilitation treatment. The patient required 24-hour inpatient detoxification treatment and rehabilitation treatment prior to the transfer to a long-term substance residential treatment. The recommendation is to overturn the previous decision and approve coverage for inpatient substance rehabilitation/detoxification treatment. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the admission at an inpatient detoxification level of care f is substantiated.