Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid Dependence.

Treatment: Admission to the substance abuse inpatient detoxification level of care.

The insurer denied coverage for admission to the substance abuse inpatient detoxification level of care.

The denial is overturned.

This patient was admitted to inpatient substance detoxification treatment. He had withdrawal symptoms including nausea, tremors, sweats, stomach cramps, body aches, chills, anxiety, loose stool, visual disturbances, fatigue, agitation, and headache. He had a Clinical Opiate Withdrawal Score (COWS) of 8 and Clinical Institute Withdrawal Assessment for Alcohol (CIWA) of 12. He had been drinking 3 pints of vodka per day, 30 bags of heroin per day, $50 crack/cocaine per day, and cannabis daily. He had multiple inpatient detoxifications and had continued relapses. His toxicology was positive for heroin, benzodiazepines, cocaine, barbiturates, and fentanyl. He also was homeless and had bipolar disorder and was taking psychotrophic medications Wellbutrin and Remeron. He had an overdose episode also in the past. He was put on a Librium protocol taper and was then discharged.

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. This patient could not safely be treated in a less restrictive detoxification treatment level of care as he was at risk for severe, complicated, and life threatening withdrawal due to large amounts of daily alcohol use, heroin, and cocaine use as well as cannabis use and had active withdrawal symptoms including nausea, tremors, sweats, stomach cramps, body aches, chills, anxiety, loose stool, visual disturbances, fatigue, agitation, and headache. He reportedly had a COWS of 8 and CIWA of 12. 

According to the Level of Care Determination (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting as he continued to use large amounts of  alcohol, heroin, and crack/cocaine daily despite multiple past inpatient substance detoxification treatments and he required and needed detoxification medication to modify withdrawal including a Librium taper protocol and needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including severe and life threatening withdrawal symptoms. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use so he required inpatient detoxification protocol treatment. He also was at risk for another overdose due to his alcohol, heroin, and crack/cocaine use.  He had comorbid psychiatric issues including bipolar disorder and also had lacked supports as he was homeless. He was using large amounts of serious substances of use including alcohol, heroin, and crack/cocaine daily and had active withdrawal symptoms with lack of supports and had multiple relapses despite multiple past inpatient detoxification treatments. Also, he reportedly had a past overdose episode and was at high risk for another one if continuing to use the amounts of these substances daily. It was considered medically necessary for him to have inpatient detoxification treatment in a hospital setting. 

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

The insurer's denial of coverage for admission to the substance abuse inpatient detoxification level of care is reversed. Medical Necessity is substantiated.