Appeal type: Medical necessity
Decision: Overturned

Treatment: Inpatient Substance Abuse Admission

The insurer denied the inpatient substance abuse admission. The denial was reversed.

This is a male patient with a history of depression and polysubstance abuse. It was reported the patient had several past substance abuse treatments with relapses. He presented to an alcohol and substance treatment facility with complaints of withdrawal symptoms including sweats, nausea, dry heaves, and agitation. He had a Clinical Institute Withdrawal Assessment (CIWA) score of 9. The patient reported smoking several cannabis joints per day and smoking multiple bags of heroin over the past month. The patient was treated with a Librium taper, Campral to assist in targeting alcohol craving and Remeron for sleep and depression. The patient was discharged to a substance rehabilitation treatment facility when a bed became available. 

The 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 drinking large amounts of alcohol, using cocaine, heroin, and cannabis and was at risk for overdose. It was not likely that the patient could attend an outpatient substance detoxification treatment due to his continued use despite past inpatient substance treatments. Thus, the patient required inpatient level of care for his substance detoxification treatment. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24-hour treatment as he needed detoxification medications including Librium to modify withdrawal and had a long history of heavy heroin and alcohol use as well as cocaine, other opiates, and cannabis use putting the patient at high risk for overdose and needing 24 hour treatment due to this risk. The patient was noted to continue to use large amounts of serious substances and alcohol so outpatient treatment for detoxification was not considered safe as the patient needed 24-hour monitoring and treatment for detoxification. The patient was also at risk for severe, complicated, and life threatening withdrawal due to the large amount of his daily alcohol use. The patient was considered a high risk for relapse and even required Campral to ease his urges. The patient needed to be discharged from this hospital setting to an inpatient substance/alcohol rehabilitation setting to ensure that the patient did not relapse prior to the rehabilitation treatment. However, inpatient substance/alcohol rehabilitation setting did not have a bed available so the patient required continued inpatient treatment to prevent relapse outside of a 24-hour setting prior to going to this inpatient rehabilitation treatment. It was not likely that the patient would be able to remain abstinent if discharged home after the detoxification if he did not go to the 24 hour therapeutic and supervised rehabilitation treatment from the hospital. The patient also had comorbid depression and anxiety and lacked sober supports for outpatient detoxification to be a safe and effective option. 

The health care plan did not act reasonably with sound medical judgment and in the best interests of the patient.  
The carrier's denial of coverage for the inpatient substance abuse admission is reversed.  The medical necessity is substantiated.