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202202-146023

2022

Healthfirst Inc.

Medicaid

Substance Abuse/ Addiction

Substance Abuse Treatment: Residential

Medical necessity

Overturned

Case Summary

Diagnosis: Substance Abuse

Treatment: medically supervised inpatient detoxification admission

The insurer denied coverage for medically supervised inpatient detoxification admission

The denial is overturned.

This adult male was admitted to this inpatient detoxification treatment due to alcohol withdrawal symptoms. He reported nausea, anxiety, hot and cold sweats, sleeping problems, and anxiety symptoms. He reported drinking 1 pint of liquor and two 6 packs of beer per day and using $ (dollar) 80 per day worth of cocaine. He had a positive toxicology screen for cocaine and benzodiazepines. He had bipolar disorder and was taking Risperidone and had a past psychiatric hospitalization. He had multiple inpatient detoxification treatments (at least 12 reported) and inpatient rehabilitation treatments and still was unable to stop his large amount of daily alcohol use and cocaine use. He reportedly was homeless for the past 2 months prior to admission. He reported working odd jobs to support his addiction. He was put on a Librium taper protocol and given Librium until discharge. The plan was for him to attend an inpatient substance rehabilitation treatment after detoxification was complete, but he left the facility AMA (against medical advice).

According to the LOCADTR (Level of Care Determination), the patient did require 24-hour treatment as he could not safely and effectively be treated in less restrictive detoxification settings as he continued to use large amounts of alcohol daily despite multiple past inpatient detoxification treatments and rehabilitation treatments and he required and took detoxification medication, Librium, to modify and treat withdrawal. He was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including severe and life-threatening withdrawal symptoms.

It was reported that he had detoxification medication, Librium throughout his stay. He also had a comorbid bipolar disorder with a past psychiatric hospitalization and lacked supports as he was homeless. He lacked coping skills and could not maintain abstinence so he could not safely and effectively be treated in a less restrictive level of care. The risk of life-complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use, and so he required the entire time in this medical inpatient detoxification setting including when he left AMA despite the recommendation for an inpatient alcohol/substance rehabilitation treatment after this.

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

The insurer's denial of coverage for the medically supervised inpatient detoxification admission is overturned. Medical necessity is substantiated.

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