Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment 2 days/units of Inpatient Substance Abuse

The insurer denied coverage for 2 days/units of Inpatient Substance Abuse

The denial is overturned

This is the case of a male patient who was admitted to this inpatient hospital for substance detoxification treatment. He had withdrawal symptoms including sweats, flushed face, restlessness, dilated pupils, bone and joint aches, eye tearing, runny nose, gastrointestinal (GI) upset, tremors, yawning, anxiety, and piloerection with a clinical opiate withdrawal score (COWS) as high as 20. He was using 20 bags of heroin daily by inhalation, drinking 1 Hennessy per day, smoking 2-3 blunts of marijuana or hashish, using cocaine by inhalation, and using 2 milligrams (mg) of benzodiazepines daily. He immediately relapsed after a previous inpatient detoxification treatment. He reportedly lacked supports and was homeless. The patient had a positive toxicology for tetrahydrocannabinol (THC), fentanyl, and opiates. He was put on a detoxification protocol with Methadone and treated daily for detoxification. The patient also took Valium as needed. He was supposed to be discharged to an inpatient substance rehabilitation treatment but left. 

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 and benzodiazepine use, large amounts of daily heroin including up to 20 bags per day, and cocaine use as well as cannabis/hashish use and had active withdrawal symptoms including sweats, flushed face, restlessness, dilated pupils, bone and joint aches, eye tearing, runny nose, GI upset, tremors, yawning, anxiety, and piloerection and he had a COWS as high as 20. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated in a less restrictive treatment setting. The patient continued to use large amounts of heroin and alcohol daily, cocaine, as well as cannabis/hashish daily despite past inpatient substance detoxification treatment including a recent admission in which he immediately relapsed with heroin, and he required and needed detoxification medication to modify withdrawal including Methadone daily as well as Valium as needed. He needed 24-hour treatment as he was at risk for worsened withdrawal symptoms if not in this 24-hour setting including severe and life-threatening withdrawal symptoms as well as overdose. The risk of life complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use and even 1 week after benzodiazepine use so he required inpatient detoxification protocol treatment. He lacked supports and was homeless and could not be treated in a less restrictive setting. He was using large amounts of serious substances of use including heroin, alcohol, cocaine, cannabis/hashish and had active withdrawal symptoms with lack of supports and had relapses despite past inpatient detoxification treatment. He continued to report withdrawal symptoms including sweats, dilated pupils, bone/joint aches, nasal congestion, tremors, yawning, anxiety, and irritable mood with a COWS of 9. Notes reported continued withdrawal including sweats, dilated pupils, bone/joint aches, GI upset, tremors, anxiety and irritable mood. with a COWS of 7. He reportedly left instead of staying another day for detoxification and then discharging to inpatient substance rehabilitation treatment. He still reportedly had withdrawal with a COWS of 2. 

It was considered medically necessary for him to have inpatient detoxification treatment in a hospital setting as he was at risk medically due to the large amount of multiple serious substances of use. Continued inpatient hospital treatment was medically necessary as the medical records provided enough specific evidence to support that he required this level of care. 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 2 days/units of Inpatient Substance is overturned. Medical necessity is substantiated.