Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse.

Treatment: Inpatient Substance Abuse.

The insurer denied the inpatient substance abuse.

The denial was overturned.

This is a female patient who was admitted to inpatient detoxification treatment due to alcohol, benzodiazepine, and opioid withdrawal. She had withdrawal symptoms that included tremors, nasal stuffiness, irritable mood, anxiety, joint pain, elevated heart rate, and a Clinical Institute of Withdrawal Assessment (CIWA) of 11 and Clinical Opioid Withdrawal Scale (COWS)score of 10. She reportedly was drinking 2 pints of liquor per day, using 12-16 mg of Xanax/Klonopin, and using 35-50 bags of heroin per day. She also reportedly had a diagnosis of Bipolar disorder and post-trraumatic stress disorder (PTSD) and was taking psychotrophic medication including Effexor, Seroquel, Trileptal, Doxepin, and Buspirone. She had a past inpatient detoxification treatment and inpatient detoxification/ rehabilitation treatment in 2018. She was put on an Ativan and Methadone protocol and was discharged to inpatient substance rehabilitation treatment. 
  
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. In this case this patient had been using large amount of benzodiazepine daily as well as alcohol daily putting her at high risk for severe, complicated, and life threatening withdrawal. She also had active withdrawal symptoms including a CIWA of 11. She also had been using very large amounts of heroin and had active withdrawal with a COWS of 10. She was at very high risk of overdose with the large amount of benzodiazepine and heroin as well as alcohol use so she required only inpatient hospital detoxification then.  

According to the 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, benzodiazepines, and heroin and also needed 2 detoxification medications including Ativan and Methadone for detoxification and continued to have withdrawal symptoms. She continued to use large amounts of alcohol, benzodiazepine, and heroin daily despite past inpatient detoxification treatment in late 2018 for 5 days and a past inpatient detoxification/ rehabilitation treatment for 19 days in 2018. She lacked the coping skills to stop alcohol and substance use and needed 24 hour hospital detoxification as she was considered a high risk medically for life threatening withdrawal including delirium tremens, and she also was a high risk for overdose.  She reportedly was discharged after still receiving detoxification medication and was discharged to inpatient substance rehabilitation treatment. 

Inpatient hospital detoxification treatment was medically necessary. It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient then.

Based on the above, the medical necessity for Inpatient Substance Abuse is substantiated.  The insurer's denial is overturned.