Diagnosis: Substance Detoxification

Treatment: Inpatient Admission

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

This is a female patient admitted to inpatient substance detoxification treatment in early 2019 for detoxification from heroin and alcohol. She reportedly had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 16 and Clinical Opiate Withdrawal Scale (COWS) of 17 and had withdrawal symptoms including tremors, sweats, nausea, vomiting, joint pain, yawning, sleeping problems, diarrhea, irritable mood, and anxiety. She had past inpatient substance detoxification and rehabilitation treatments. She reportedly had a past psychiatric hospitalization for bipolar disorder. She was started on Methadone and Librium for detoxification. She completed detoxification several days after her admission and was then converted to rehabilitation status.

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. It also states that patients with significant alcohol use including large quantities and long durations of use are at higher risk for delirium tremens which is considered a life threatening condition. It is reported that delirium tremens can occur within 3-4 days after stopping alcohol use. This patient was having withdrawal symptoms on admission and continued to have reports of withdrawal symptoms throughout the first several days of admission and continued with two detoxification medications and had the detoxification treatment reportedly completed. She took detoxification medication to modify withdrawal including Librium and Methadone and detoxification was reportedly completed within the fifth day of her admission. She was at risk for complicated and life threatening withdrawal symptoms 3-4 days after admission and considered a risk and in need of at least 96 hours or 4 days of treatment in this inpatient hospital as a result.

The carrier's denial of certain days of coverage for the inpatient hospital services is modified.