Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Dependence

Treatment: Inpatient substance detoxification 

The insurer has denied coverage for inpatient substance detoxification treatment. The denial was reversed.

This is a male patient who was admitted for inpatient substance detoxification treatment due to detoxification from opiates. He had withdrawal symptoms including tremors, nausea, sleeping problems, nasal congestion, irritable mood, anxiety, sweats, teary eyes, and had a Clinical Opiate Withdrawal Scale (COWS) of 12. He was placed on detoxification medication as he had a Methadone protocol and also took Clonidine. He was using bags of intravenous (IV) heroin, IV cocaine, smoking cannabis, and taking multiple OxyContin pills daily. He had past substance outpatient rehabilitation treatment and lacked coping skills to stop substance use. He also reportedly took Venlafaxine. He took Methadone for opioid detoxification with the last dose reportedly given the day before discharge.

The insurer denied coverage for inpatient substance detoxification treatment as not medically necessary treatment. They stated that his vital signs were stable, he did not have mental health or medical conditions requiring 24 hour treatment then, and they recommended a less restrictive level of care then.

The medical records support the necessity for inpatient substance detoxification treatment. The American Psychiatry Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicate 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. In this case this patient was using large amounts of multiple serious substances including heroin, OxyContin, cocaine, and cannabis daily and was at elevated risk for death from overdose and also at risk for severe withdrawal symptoms as he was using large amounts of heroin, OxyContin, and cocaine.

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 substances despite past substance treatment and lacked coping skills to stop use, needed detoxification medications including Methadone and Clonidine to modify withdrawal from heroin and OxyContin, had long term multiple serious substances of use, and he needed 24 hour treatment then as he was at risk for worsened and severe withdrawal symptoms if not in this 24 hour setting then, and he likely would have relapsed again as evidenced by inability to stop using multiple serious substances of use. He had active withdrawal symptoms on admission and he required and received detoxification medication until the day before discharge. He required 24 hour inpatient substance detoxification treatment then and it was not likely that he could safely or effectively be treated for detoxification from these multiple serious substances in an outpatient detoxification setting, and he could not stop use to have outpatient detoxification treatment.

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