Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the Inpatient Hospital Admission. 

The denial is overturned. 

This is a male patient who was admitted to inpatient hospital treatment after a heroin overdose.  He reportedly was using intravenous (IV) heroin daily and it was reported that he was unresponsive and cyanotic and that his roommate gave him Narcan.  He started breathing but was still unresponsive so he was taken to the hospital.  He reportedly had a history of seizures in the context of substances.  He was lethargic and had elevated blood pressure.  He was in a past Methadone program.  He was given Depakote, IV fluids, and was in neuro checks every (q) 4 hours but left against medical advice (AMA). 

The patient was a high risk patient in need of hospital treatment.  He reportedly was found unresponsive due to excessive heroin use and an overdose that required 12 milligrams (mg) of Narcan.  He had significant substance use with serious substances of use including crack/cocaine 3-4 times per week in addition to daily IV heroin use which put him at high risk for death due to overdose which almost occurred.  He was a high risk for suicide due to having a past reported suicide attempt and being non-compliant with psychotropic medications for bipolar disorder.  He had reports of seizures due to substance use and contracted an infection due to use so he was at risk both medically and psychiatrically.  It was reported that he started having opioid withdrawal including chills, shakes, and anxiety and had a Clinical Opiate Withdrawal Scale (COWS) of 5 so he also required inpatient detoxification from heroin but left AMA.  He was considered at risk for more severe withdrawal if not detoxified. 

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, and reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. 

This patient had comorbid medical conditions complicating the management of withdrawal as he was found unresponsive and cyanotic due to heroin use and required 12 mg of Narcan.  He also had past reported seizures due to substances and also had high blood pressure on admission, as well as diabetes.  He also reportedly began presenting with withdrawal symptoms including chills, shakes, and anxiety. 

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 he continued to use multiple serious substances of use despite serious negative consequences to use, including an overdose on admission in which he was unresponsive and had medical issues.  He also needed detoxification medications to modify withdrawal, had long term multiple substances of use including using heroin and crack/cocaine and he needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then.  It was unlikely that he would remain abstinent while still having withdrawal symptoms also so he required more time in this treatment setting even though he left AMA. 

It did not appear that the health care plan acted reasonably, with sound medical judgment, or in the best interests of the patient. 

The carrier's denial of coverage for the Inpatient Hospital Admission is overturned.  The medical necessity is substantiated.