Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use

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

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

The denial is overturned. 

This is a male patient with a history of substance use including cocaine use disorder, nicotine dependence, and opiate dependence who presented to the hospital with a chief complaint of withdrawal symptoms. He was admitted to this inpatient hospital for substance detoxification treatment. He had withdrawal symptoms including chills, flushing, tremors, dilated pupils, nasal congestion, diffuse aches, gastrointestinal upset, yawning, and anxiety. He reportedly had a Clinical Opioid withdrawal Scale (COWS) score of 11 which then increased to 13 on day 2 of admission. He was using 10-12 bags of heroin daily, cocaine, and 4 milligrams (mg) of benzodiazepines (Klonopin) daily. He also reportedly was using methadone 50 mg per day a few times per week. He reportedly had a positive toxicology for cocaine, fentanyl, opiates, and methadone. He had multiple past inpatient substance detoxification treatments. He was unemployed, single and had no children. He was put on a methadone detoxification protocol due to his withdrawal symptoms for detoxification. He also had a Psychiatry consultation and had a past history of major depressive disorder and past psychiatric hospitalizations and he was prescribed Trazodone. He reportedly left Against Medical Advice (AMA) on day 3 of admission.

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. This was the case with this patient. This patient had multiple past substance detoxification treatments and still was using heroin daily and cocaine as well as Klonopin which put him at risk of overdose and severe withdrawal. It was not likely that he could be treated in a less restrictive substance detoxification treatment due to his continued use despite past inpatient substance detoxification treatments so he required inpatient substance hospital detoxification treatment. He also had reports of worsened withdrawal as his COWS score increased from 11 to 13 so he was more at risk for severe withdrawal and in need of 24 hour hospital detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24 hour treatment from day 1 to day 3 of admission as he needed detoxification medication, methadone, to modify withdrawal and prevent more severe withdrawal. He reportedly was using large amounts of heroin including 10-12 bags per day with cocaine, and Klonopin, so he was considered a high risk medically for overdose and more severe withdrawal. He was considered at risk for complicated and life threatening withdrawal due to his large amount of daily Klonopin use in addition to his large amount of heroin and cocaine use. 

Inpatient acute hospital treatment for substance detoxification was medically necessary.  It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

The medical necessity for the admission to the substance abuse inpatient detoxification level of care is substantiated. The insurer's denial is overturned.