Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient detoxification admission

The insurer denied coverage for inpatient detoxification admission. The denial is reversed. 

This patient is a male admitted to this inpatient substance detoxification treatment in this hospital for heroin, cocaine, and cannabis detoxification. He had withdrawal symptoms including tremors, joint pain, anxiety, dilated pupils, chills/flushing, yawning, and diffuse discomfort. He was inhaling multiple bags of heroin daily with an almost 3 decades history of use, smoking tens of dollars daily of crack/cocaine, and smoking THC per day. He was put on a Methadone taper and also used Clonidine for detoxification. He was homeless, lacked coping skills for sobriety, was not able to identify relapse triggers, and had past legal problems as well as an inability to work due to use. He had past inpatient detoxification treatments and was unable to maintain abstinence. He had extreme cravings and left against medical advice (AMA).

The insurer denied coverage for inpatient substance detoxification treatment in this hospital as not medically necessary treatment. This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment in this hospital as the chart notes provided enough specific evidence to support that he required 24-hour hospital detoxification 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, 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 as he had continued use of multiple substances including crack/ cocaine, heroin, and cannabis putting him at risk of severe withdrawal or overdose. He had past inpatient detoxifications, as well as legal issues and he was unable to work due to substance use; therefore, he required 24-hour hospital detoxification treatment to give him the best chance for detoxification and then rehabilitation. He was considered a medical risk and in need of 24- hour hospital detoxification due to his risk of severe withdrawal and overdose, as well as medical consequences of substance use due to his large amount of daily use of serious substances. He could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use multiple substances after prior inpatient detoxification treatments. 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 for detoxification in a less restrictive setting. 

As a result, reverse the previous decision and approve coverage for inpatient substance detoxification treatment in this hospital. The health care plan did not act reasonably or with sound medical judgment or in the best interests of the patient.

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