Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Drug Abuse

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to this inpatient hospital for detoxification treatment. The patient reportedly had withdrawal symptoms including anxiety, disorientation to place, enlarged pupils, yawning, piloerection, irritable and anxious mood and had a Clinical Opiate Withdrawal Scale (COWS) of 12 and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 4. The patient reportedly was using large amounts of Alprazolam including up to 20 milligrams (mg) per day and drinking a 12 pack of alcohol, using 4-6 bags of both intravenous (IV) heroin and IV cocaine, and was using 2 bags of methamphetamine. The patient's toxicology was positive for opiates, Phencyclidine (PCP), Methylenedioxymethamphetamine (MDMA), benzodiazepines, cocaine, methadone, and tetrahydrocannabinol (THC). The patient reportedly had a past inpatient substance detoxification treatment for 6 days. The patient reportedly had hepatitis C. The patient reportedly was unemployed. The goal was to complete detoxification treatment and then go to inpatient rehabilitation treatment. The patient reportedly was put on an Ativan protocol and taper for detoxification. 

The insurer denied coverage for inpatient hospital treatment as not medically necessary treatment then. They stated that the patient did not require 24 hour hospital treatment and they recommended a less restrictive level of care then.

The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment and the medical records provided enough specific evidence to support that the patient required this level of care then. In this case this patient was considered in need of 24 hour substance rehabilitation treatment as the patient reportedly was using large amounts of multiple serious substances of use putting them at risk for severe, complicated, and life threatening withdrawal as well as overdose or medical consequences to use. The patient also reportedly lacked the coping skills and sober support network to remain abstinent in a less restrictive level of care as evidenced by the fact that the patient had could not maintain sustained abstinence despite a past inpatient substance detoxification treatment. The patient reportedly was using large amounts of serious substances of use including using large amounts of Alprazolam including up to 20 mg per day and drinking a 12 pack of alcohol, using 4-6 bags of both IV heroin and IV cocaine, and was using 2 bags of methamphetamine. This was considered a very large amount of substance use and alcohol use and the patient was at risk for overdose and medical consequences to use as well as life threatening withdrawal. The patient was considered unable to be treated in a less restrictive level of care and required inpatient hospital treatment due to their active withdrawal symptoms and risk of worsened withdrawal and lack of coping skills to maintain abstinence outside of a 24 hour inpatient setting. The patient reportedly was considering inpatient substance rehabilitation after completion of this detoxification treatment. This was a high risk patient who needed inpatient hospital treatment. As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance detoxification treatment. It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the individual then.

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

The medical necessity for medically supervised inpatient detoxification is substantiated.