Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use. 

Treatment: Medically supervised inpatient detoxification admission.

The insurer denied coverage for the medically supervised inpatient detoxification admission. 

The denial is overturned. 

This is a female patient who was admitted to inpatient hospital treatment for detoxification as she had withdrawal symptoms including tremors, sleeping problems, irritable mood, and teary eyes and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 8.  She was using crack by smoking, drinking 1 pint of alcohol per day, and had a reported history of opiate use including heroin and past methadone treatment.  She had multiple past inpatient detoxifications and also inpatient rehabilitation treatment and could not maintain abstinence. She lacked coping skills to remain sober and needed help to identify triggers and stressors. She was put on an Ativan taper and received Ativan for detoxification. She was discharged to an inpatient substance rehabilitation treatment. She also had depression and anxiety and had been noncompliant with medications Gabapentin and Amitriptyline. She was unemployed and depended on family for shelter. She also did not have a sober support system as her significant other was using heroin.

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 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. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 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 crack daily despite multiple inpatient detoxification treatments and an inpatient rehabilitation treatment.  Also, she required and received detoxification medication-Ativan.  She was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including possible life threatening withdrawal such as delirium tremens.  She required 24 hour medical hospital treatment and was considered a high risk patient for more complicated and life threatening withdrawal.  She required inpatient detoxification prior to inpatient rehabilitation treatment. 

It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

The insurer's denial of coverage for the medically supervised inpatient detoxification admission is overturned. Medical Necessity is substantiated.