Diagnosis: Substance use.
Treatment: Inpatient admission.

The insurer denied coverage for the inpatient admission. The denial is overturned.

This is a male patient, who was admitted to an inpatient hospital for heroin detoxification. The patient presented with withdrawal symptoms, including gastrointestinal upset and aches, nausea, diarrhea, chills, goose bumps, and generalized body aches. The patient reportedly was using up to 8 bags of heroin daily. The patient also reportedly was using cannabis. The patient reported 27 pounds weight loss with a body mass index (BMI) of 16.9. The patient's substance use history was significant for 6 past inpatient substance detoxification treatments and 2 inpatient substance rehabilitation treatments. The patient was also unemployed. The patient was admitted and was treated with a methadone taper.

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 are candidates for inpatient detoxification treatment. In this case, this patient had been using heroin daily and cannabis, and he was at risk for death from overdose of heroin and also at risk for severe withdrawal.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of heroin daily including up to 8 bags of heroin daily despite 6 past inpatient substance detoxification treatments and 2 past inpatient substance rehabilitation treatments. The patient also required and received detoxification medication, methadone, to modify his withdrawal from heroin. The patient presented with a long history of polysubstance use including heroin and cannabis, and needed 24-hour treatment then, as he was at risk for worsened withdrawal symptoms including severe withdrawal and even overdose. The patient also had active withdrawal symptoms including gastrointestinal upset and aches, nausea, diarrhea, chills, goose bumps, and generalized body aches and was at risk for severe withdrawal and could not detoxify outside of this hospital setting. The patient likely would have relapsed again, as evidenced by his history of relapsing after 6 past inpatient substance detoxification treatments and 2 inpatient substance rehabilitation treatments.

Based on the review of the medical record and literature, the inpatient admission was medically necessary for this patient's substance detoxification.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the inpatient admission is substantiated. The insurer's denial should be overturned.