As a clinician in the substance abuse field, I have had my share of run-ins with insurance companies.  In fact over the years it has been a battle to get reimbursed for many, if not all of the services delivered. Not only are policy holders and beneficiaries at the mercy of the insurance companies on what services will be covered, or fall within the network, or even be deemed necessary, providers are as well.

 Case in point:

23 year old client. Male.

Prior failed out-patient treatment for substance abuse

Using up to 15 milligrams of various benzodiazepines daily

Intravenous heroin use 4-5 times per week

Pure fentanyl powder taken intranasally and/or intravenously every day, sometimes up to 150mcg daily

Oxycodone use, generally one to two times a week

Sporadic cocaine and alcohol use

Subsolv, a buprenorphine brand used occasionally

 Admits to two overdoses within the last week; one requiring hospitalization and administration of narcan.  None of which he remembers as a result of still being intoxicated despite the use of opiate blockers to pull him back to consciousness during the overdose. 

 The general appearance of the client is that of a malnourished young man.  He is very thin, frail even with large dark circles under both eyes.  His skin tone is pale and mottled and as I talk to him, I observe profuse sweating only hours after his last self-administration of drugs.

 His parents requested me to intervene and assist with getting him placed into a treatment center.  They wanted to save their son’s life.  He agreed to enter into treatment and get his life on track.

This client’s father has a comprehensive insurance policy through his work that covers his son.

 The response of the insurance company was that said client does not meet the medical necessity of detoxification.  Detox is an integral portion of almost any treatment program as it is the initial phase in which an individual is monitored while coming off drugs and as they experience withdrawal symptoms.  The person described above who would experience withdrawal symptoms from IV heroin, benzodiazepines, fentanyl powder, buprenorphine and oxycodone does not meet the medical need for detoxification.

 For those of you who are unfamiliar with withdrawal symptoms, I will explain.  Withdrawal from opiates begins with mild to moderate anxiety and cravings which rapidly develop into extreme anxiety and cravings.  If you can last through that you will then experience hot and cold chills with sweating, running nose, sneezing, watery eyes, profuse tiredness and lethargy unfortunately coupled with an insane inability to sleep.  Anger, fear, paranoia, irritability, and depression go with this.  Included with the above, is gastrointestinal distress possibly with nausea and sometimes severe vomiting as well as diarrhea.  Dehydration becomes a major risk.

 Benzodiazepines withdrawal brings the onset of anxiety, sometimes leading to panic attacks, chest pains, and intense cravings which can come on rapidly.  Tremors, shaking, grand and petit mal seizures, the feeling of electricity running through the body, sweating, headaches, intense fear, misemotion, irritability and panic are all possible. 

 It has been theorized by many experts on addiction that one of the strongest initial barriers to an individual seeking help and treatment for alcohol or drug addiction is the fear of going through withdrawal symptoms as described above.  Detoxification programs are in place to ease that fear, assist in helping the addict physically feel more comfortable thereby making further treatment not only accessible to addicts but POSSIBLE.  For without some sense of feeling that they CAN get through it, many addicts won’t even try.  

 The above mentioned client who experienced withdrawal symptoms was not deemed as meeting the medical necessity for detoxification services.  One wonders what those criteria are.

The client was still delivered detoxification services which he complete.  He has now entered into a treatment program and is on his way to recovery. 

 Providers and clients are at the mercy of insurance companies, who quite literally control the healthcare system.  It is not the provider (hospital, doctor, medical professional, and/or surgeon) who dictate the treatment delivered.  They can only recommend a course of treatment to which the insurance company who will authorize payment for said treatment or not.  It is then up to the client to pay out of pocket for any medical procedures not covered.

 Not medically necessary… something needs to change.

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