Diagnosis: Substance Detoxification

Treatment: Inpatient substance detoxification

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

This is a male patient who was admitted to inpatient substance detoxification treatment in early 2019 for substance detoxification treatment. He reportedly had withdrawal symptoms including tremors, sweats, joint pain, dilated pupils, nausea and vomiting, yawning, anxious mood. He had a history of using intravenous (IV) heroin and cocaine daily, and Xanax multiple times per day. He reportedly had multiple past inpatient substance detoxification and rehabilitation treatments including a recent one. He reportedly had two detoxification medications including Librium and Methadone during this admission. He was 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. In this case this patient had use of multiple serious substances including heroin, cocaine, and Xanax and was at risk for death from overdose.

The carrier's denial of coverage for the continued inpatient hospital stay for detoxification level of care is reversed. The medical necessity is not substantiated.