Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient substance detoxification

The insurer denied the Inpatient Admission. The denial was reversed. 


This is a male who was admitted to inpatient substance detoxification treatment in early 2019 due to opioid detoxification.  He had a Clinical Opiate Withdrawal Scale (COWS) of 16 and had withdrawal symptoms reported including sweats, tremors, nausea, sleeping problems, anxiety, irritable mood, agitation, headache, stomach cramps, yawning, nasal stuffiness, abnormal pupil size, and bone and joint aches.  He reportedly had legal problems related to his substance use and had to report to treatment. He was homeless and lacked support.  He was using a bundle of heroin and Percocet and Xanax, and also cannabis.  He reportedly lacked coping skills and needed to better identify relapse triggers and stressors.  He had a history of bipolar disorder and anxiety.  He reportedly had past inpatient substance treatment including an inpatient detoxification and rehabilitation treatment for 21 days and an inpatient residential rehabilitation treatment in early 2019 for 38 days.  He was still unable to maintain abstinence.  He had a 7 day Suboxone detoxification and was reportedly discharged to inpatient substance rehabilitation treatment.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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 reportedly had past substance detoxification treatment and inpatient rehabilitation treatment and still was using heroin and opiates, Xanax, and cannabis despite negative consequences to use.  It was reported that he needed better coping skills and identification of relapse triggers and could not stop use.  He was at risk of severe withdrawal and he was placed on Suboxone for a 7 day detoxification.  He likely would have had withdrawal symptoms if not for this one week detoxification and according to Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he required inpatient substance detoxification treatment as he was using large amounts of substances and he had past detoxification treatment and still was unable to maintain abstinence.  He reportedly lacked coping skills and needed to better identify relapse triggers and stressors.  He was also homeless and lacked supports.  He had a history of bipolar disorder and anxiety as well which further put him at risk.  It was not likely that he could attend an outpatient substance detoxification treatment prior to inpatient substance rehabilitation treatment due to his continued use despite past inpatient substance treatments. He required only inpatient substance detoxification treatment then and required a substantial enough detoxification length to prevent further withdrawal prior to attending the rehabilitation treatment.  He also was at risk for accidental overdose. 

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