Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorders
Treatment: Substance Abuse Inpatient Detox Admission
The insurer denied coverage for: Substance Abuse Inpatient Detox Admission
The denial is: Overturned.

This adult was admitted to inpatient hospital for substance detoxification and rehabilitation treatment. The patient reportedly was smoking $ (dollar) 30-40 per day of cocaine with last use 1 day prior to admission and had a history of use since a teenager.  The patient had a positive toxicology for opiates and cocaine. The patient reportedly could not maintain abstinence despite being in outpatient medication assisted treatment (MAT) and taking 95 milligram (mg) of Methadone per day. The patient had a history of cannabis and opiate use. The patient had a past treatment episode for substance use a few years ago. The patient reportedly had cravings and strong urges. The patient had comorbid psychiatric diagnoses of post-traumatic stress disorder (PTSD) and depression. The patient had hepatitis C and past legal charges due to possession. 
 
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. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders also reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24-hour inpatient substance rehabilitation and detoxification treatment as the patient could not maintain abstinence despite being in an outpatient substance treatment MAT and Methadone treatment. The patient's urine toxicology was positive for cocaine and opiates. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) the patient did require 24-hour treatment as the patient could not safely and effectively be treated for detoxification or rehabilitation in a less restrictive setting as the patient continued to use very large amounts of cocaine daily despite past inpatient substance treatment and despite negative consequences to use including legal charges for possession and medical consequences including hepatitis C. The patient also had comorbid psychiatric conditions including depression and PTSD which could further trigger use. The patient was considered a high risk for relapse without 24-hour therapeutic inpatient substance/alcohol rehabilitation treatment then As a result, the reviewers decision is to reverse the previous decision and approve coverage for inpatient substance detoxification and rehabilitation treatment. 

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 Substance Abuse Inpatient Detox Admission is substantiated.