Diagnosis: Opioid Withdrawal.

Treatment: Inpatient Hospital Admission.

The insurer denied coverage for Inpatient Hospital Admission.

The denial is overturned.

This is a patient admitted to the hospital for treatment of opioid withdrawal. The patient had opioid withdrawal symptoms including nausea and vomiting as much as 20 to 30 times, cold sweats, tachycardia, diarrhea, abdominal pain, poor oral intake, and had a Clinical Opiate Withdrawal Score (COWS) as high as 19. The patient had been drinking codeine a few times per day, taking 2 Percocet pills per day, and smoking cannabis 10 times per day. The patient also has a history of alcohol use. Patient had electrolyte abnormalities including a low potassium of 3.2, CO2 of 19, and bilirubin of 1.6. The patient received detoxification medication for opioid withdrawal including intravenous (IV) Methadone, IV antiemetics, IV Toradol, IV fluids, and Clonidine. Patient continued to have opioid withdrawal until the date of discharge.

The medical records provided enough specific evidence to support that the patient required this level of care. The American Psychological Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance, puts patients at high risk for complicated withdrawal. These patients are candidates for inpatient detoxification treatment. There was a recommendation from the medical team for inpatient substance treatment, but the patient declined. The patient was hemodynamically stable and not considered in further withdrawal at day of discharge. The medical records support that patient was at risk for more severe opioid withdrawal due to the large amount of daily opiate use and was at risk for overdose. Chart reports of inpatient medical issues included severe abdominal pain and electrolyte abnormalities and the patient required and received treatment for detoxification.

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 inpatient admission is overturned. Medical necessity is substantiated.