Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance and alcohol use disorder 
Treatment:  Inpatient detoxification admission 

The insurer denied coverage for inpatient detoxification admission. The denial is reversed.  

This patient is a male was admitted to this inpatient substance detoxification treatment for alcohol, Xanax, and heroin detoxification.  He had withdrawal symptoms including tremors, joint pain, irritable mood, and anxiety.  He reportedly had been drinking 1/2 pint of vodka per day with 6 beers for with over three decades, using 4 mg of Xanax per day for more than a decade, and inhaling 3 bags of heroin per day for over a decade.  He had past reported multiple inpatient substance detoxification and rehabilitation treatments.  He also reportedly had a diagnosis of bipolar depression in addition to his alcohol, Xanax, and heroin use disorders.  He also had past psychiatric hospitalizations for past reported suicide attempts.  He was put on a Librium protocol for detoxification and was discharged with a referral to substance residential rehabilitation treatment scheduled.  

The insurer denied coverage for inpatient substance detoxification treatment.  This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment, as the as the chart notes did provide enough specific evidence to support that he needed this level of care.  The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, who fail to be cooperative with or benefit from outpatient detoxification, who currently abuse of other substances, who have very heavy use or tolerance, putting one at high risk for complicated withdrawal, are candidates for inpatient detoxification treatment.  In this case this patient had use of multiple substances, including large amounts of alcohol, Xanax, and heroin, and was at risk for death from overdose as result of this use.  

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting, as he continued to use multiple serious substances of use despite multiple past inpatient substance detoxification and rehabilitation treatments, and he needed two detoxification medications including Librium and Clonidine to modify withdrawal from alcohol, Xanax, and heroin.  Also, he had reports of long term multiple substances of use and was at risk for worsened withdrawal symptoms if not in this 24-hour setting then, including severe, complicated, and life threatening withdrawal, such as delirium tremens, due to the large amount of alcohol and Xanax use.  Also, he likely would have relapsed again as evidenced by relapsing after past treatments.  

As a result, the recommendation is to reverse the previous decision and approve coverage for inpatient substance detoxification.  It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

Based on the above, the medical necessity for the inpatient detoxification admission is substantiated.  The insurer's denial is reversed.