Clinical UM Guideline


Subject:Substance Abuse Treatment
Guideline #:  CG-BEH-04Current Effective Date:  02/17/2014
Status:RevisedLast Review Date:  02/13/2014

Description

The medical necessity criteria outlined in this guideline for each level of care relating to substance abuse treatment includes three categories; Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria includes descriptions of the Covered Individual's condition and circumstances. Intensity of Service criteria describes the services being provided and these criteria must be met for admission and continued stay. For continued authorization of the requested service, Continued Stay criteria must be met along with Severity of Illness criteria.

This document addresses substance abuse treatment for:

Please see the following related document(s) for additional information:

Clinical Indications

Inpatient Acute Detoxification

Medically Necessary:

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) Substance Dependence diagnosis for inpatient acute detoxification treatment. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have one of the following:

  1. Nature and pattern of use of abused substance (including frequency and duration) predicts the potential for clinically significant withdrawal necessitating 24-hour medical intervention to prevent complications and that is not appropriate for a lower level of care- e.g., alcohol and benzodiazepine withdrawal (note: withdrawal from stimulants or marijuana alone generally does not require a medical detoxification and opiate detoxification is often appropriate for a lower level of care); OR
  2. Presence of active withdrawal symptoms that cannot be safely or effectively managed at a lower level of care-e.g., tremors, unstable vital signs, diaphoresis, gastrointestinal (GI) disturbances, agitation, withdrawal hallucinations, confusion or disorientation or seizures.

Note: Covered Individuals who experience severe psychological withdrawal symptoms may require 24-hour care, even though they do not meet the detoxification criteria. Please refer to rehabilitation and psychiatric criteria.

Intensity of Service (IS)

Must have all of the following to qualify and must still meet one SI Criteria:

  1. Documentation of blood and/or urine drug screen was ordered upon admission; AND
  2. Multi-disciplinary problem-focused treatment plan which addresses psychological, social, medical, substance abuse, and aftercare needs, which is amended in a timely and appropriate manner as indicated; AND
  3. Physician visits at least daily, seven (7) days a week; AND
  4. 24-hour skilled nursing (by either a registered nurse [RN] or licensed vocational nurse/licensed practical nurse [LVN/LPN]); AND
  5. Medication management of withdrawal symptoms tailored to the Covered Individual's individual need; AND
  6. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans with the preferred outpatient visit within one week of discharge; AND
  7. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's primary care physician (PCP), providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  8. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed; AND
  9. All therapeutic services provided by licensed or certified professional in accordance with state laws.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress in treatment is being documented and the Covered Individual is not stable enough to be treated at a lower level of care.

Not Medically Necessary:

Inpatient acute detoxification is considered not medically necessary when the above criteria are not met.

 

Inpatient Acute Rehabilitation

Medically Necessary:

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Substance Dependence diagnosis for inpatient acute rehabilitation. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. Covered Individual no longer meets detoxification SI criteria; AND
  2. Covered Individual has a severe co-morbid medical or psychiatric disorder, which requires 24-hour acute hospital care; AND
  3. There is evidence of major life impairments in at least two (2) areas of functioning (work/school, family, activities of daily living [ADL's], interpersonal); AND
  4. The Covered Individual has expressed an interest or desire to work towards the goals of treatment and recovery, at the time of admission or shortly thereafter.

 Intensity of Service (IS)

Must have all of the following to qualify:

  1. 24-hour skilled nursing care (by either an RN or LVN/LPN); AND
  2. Physician visits at least daily, seven (7) days a week; AND
  3. Programming provided will be consistent with the Covered Individual's language, cognitive, speech and/or hearing abilities; AND
  4. Implementation of individualized, problem-focused treatment plan, which includes, but is not limited to:
    1. Completion of personal substance abuse history with acknowledgement of consequences of use.
    2. Program has provisions for Covered Individual to access psychiatric treatment as needed for a dual diagnosis.
    3. Initiation or continuation of relapse/recovery program with identification of relapse triggers.
    4. Supervised attendance at community-based recovery programs when appropriate and available.
    5. Drug screens as clinically appropriate and at random.
    6. Family program and involvement in treatment, as appropriate. For adolescents, this includes weekly individual family therapy, unless clinically contraindicated; AND
  5. Discharge planning initiated on the day of admission and includes community based recovery programs and appropriate care plans. An outpatient visit within one week of discharge is expected; AND
  6. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  7. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed; AND
  8. All therapeutic services provided by licensed or certified professional in accordance with state laws.

 Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress in treatment is being documented, and the Covered Individual is still participating, following recommendations and continuing to show a level of motivation consistent with this intensity of treatment being potentially beneficial, but the symptoms and behaviors that required this level of care are still present to the extent that treatment on a lower level of care would not be sufficient.

Not Medically Necessary:

Inpatient acute rehabilitation is considered not medically necessary when the above criteria are not met.

 

Residential Treatment Detoxification

Medically Necessary:

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Substance Dependence diagnosis for residential treatment detoxification. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Nature and pattern of use of abused substance (s) (including frequency and duration) predicts the potential for clinically significant withdrawal necessitating 24-hour medical intervention to prevent complications and is not appropriate for a lower level of care - e.g., alcohol and benzodiazepine withdrawal (note: withdrawal from stimulants or marijuana alone generally does not require a medical detoxification and opiate detoxification is generally appropriate for a lower level of care).

Presence of any of the following may necessitate an acute hospital level of care:

    1. A complicating psychiatric illness that requires inpatient treatment; OR
    2. A withdrawal history of delirium tremens, seizures, hallucinations or acute psychotic reaction secondary to chronic alcohol use and/or polysubstance drug use; OR
    3. An unstable medical illness that requires daily care by a consulting physician; OR
    4. Presence of active withdrawal symptoms that cannot be safely or effectively managed at a lower level of care.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Documentation of blood and/or urine drug screen results upon admission; AND
  2. Multi-disciplinary problem-focused treatment plan that addresses psychological, social (including living situation and support system), medical, substance abuse and rehabilitation needs which is re-evaluated and amended in a timely and medically appropriate manner as indicated; AND
  3. Examination by a physician within 24 hours of admission and physician visits on a daily basis while in detoxification; AND
  4. 8 hour skilled nursing (either an RN or LVN/LPN) on site with 24-hour availability.  [Note: If the Covered Individual's medical symptoms require 24-hour nursing care for assessment, frequent administration of medication, monitoring of vital signs and other services only provided by a nurse, then acute inpatient detoxification is required]; AND
  5. Medication management of withdrawal symptoms; AND
  6. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans; AND
  7. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  8. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed; AND
  9. All therapeutic services provided by licensed or certified professional in accordance with state laws.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress in treatment is being documented and the Covered Individual is not stable enough to be treated at a lower level of care.

Not Medically Necessary:

Residential treatment detoxification is considered not medically necessary when the above criteria are not met.

 

Residential Treatment Center (RTC)

Medically Necessary

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Substance Abuse and/or Dependence diagnosis for residential treatment center treatment. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must meet criteria 1 or 2, as well as 3 to qualify:

  1. Acute psychiatric symptoms that would interfere with;
    1. The Covered Individual maintaining abstinence; AND
    2. Recovery outside of a 24 hour structured setting; AND
    3. Represent a deterioration from their usual status; AND
    4. Include either self injurious or risk taking behaviors that poses risk serious harm to the Covered Individual or others and cannot be managed outside of a 24 hour structured setting; OR
  2. Acute medical symptoms that would likely interfere with the Covered Individual maintaining abstinence and recovery outside of a 24 hour structured setting; AND
  3. Evidence of major functional impairment in at least 2 domains (work/school, ADL, family/interpersonal, physical health).

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Evaluation by a qualified physician within 48 hours of admission and weekly visits by a qualified physician if dually diagnosed and psychiatric symptoms identified as a reason for admission requiring this level of care; AND
  2. Physical exam and lab tests done within 48 hours if not done prior to admission, and eight (8) hour on-site nursing (by either an RN or LVN/LPN) with 24 hour medical availability to manage medical problems if medical instability identified as a reason for admission requiring this level of care; AND
  3. Programming provided will be consistent with the Covered Individual's language, cognitive, speech and/or hearing abilities; AND
  4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  5. Within 48 hours, an individualized, problem-focused treatment plan is done, based on completion of a detailed personal substance use history, including identification of consequences of use and identifying individual relapse triggers as goals; AND
  6. The treatment would include the following at least once per day, and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy and activity group therapy; AND
  7. Family supports identified and contacted within 48 hours and family/primary support person participation in treatment at least weekly unless contraindicated. For adolescents, this includes weekly individual family therapy, unless clinically contraindicated; AND
  8. Discharge planning completed within one (1) week of admission including identification of community/family resources, sober supports, connection or re-establishment of connection to community based recovery programs and professional aftercare treatment; AND
  9. Drug screens used after all off-grounds activities and whenever otherwise indicated; AND
  10. All therapeutic services provided by licensed or certified professionals in accordance with state laws; AND
  11. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered Individuals will be prepared to receive the majority of their rehabilitation in a community setting; AND
  12. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed; AND
  13. All therapeutic services provided by licensed or certified professional in accordance with state laws.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have all the following to qualify:

  1. Progress toward all goals in the treatment plan must be documented in weekly treatment plan reviews. If progress is not being achieved, then the treatment plan must be revised with achievable treatment goals; AND
  2. The Covered Individual is still participating, following recommendations and continuing to show a level of motivation such that treatment goals can be achieved.

Not Medically Necessary:

Residential treatment is considered not medically necessary when the above criteria are not met.

 

Partial Hospitalization Program (PHP)

Medically Necessary:

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Substance Abuse and/or Dependence diagnosis for partial hospitalization program (PHP) treatment. Co-morbid psychiatric conditions frequently occur and should be assessed upon admission. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. Symptoms or behaviors that could be treated must be present that would likely progress to a level of dangerousness or failure of self care that would require inpatient treatment without a structured treatment setting of at least six (6) hours duration a day; AND
  2. Significant functional impairment as evidenced by inability to work or attend school, impaired self care and significant conflicts with the support environment; AND
  3. The Covered Individual does not also meet criteria for IOP; AND
  4. PHP could help stabilize the social environment to an extent that would allow continued treatment of Covered Individual at a lower level of care; AND
  5. The Covered Individual has demonstrated a level of motivation that is consistent with PHP level treatment being of potential benefit; if the primary purpose of PHP is for motivational enhancement, then there must be evidence of psychiatric or medical risks that are too high for treatment at a lower level of care.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Multidisciplinary treatment provided at least six (6) hours a day. The frequency of attendance per week may vary according to clinical needs and progress; AND
  2. Nursing and MD treatment is documented if needed as evidenced by acute medical or psychiatric interventions being listed on the treatment plan; AND
  3. Programming provided is consistent with the Covered Individual's language, cognitive, speech and/or hearing abilities; AND
  4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  5. An individualized treatment plan is implemented with anticipated dates of completion that are tied to the Covered Individual's needs, not a fixed program schedule, and includes:
    1. Completion of a personal substance abuse history with acknowledgement of consequences of use.
    2. Initiation or continuation of relapse/recovery program with identification of relapse triggers.
    3. Goal of attendance at community-based recovery programs-to be attended at least two (2) times per week or documented rationale as to why this should not be required.
    4. Drug screens are obtained on a random basis with evidence of an adjustment to the treatment plan if results are positive.
    5. Family involvement in treatment as appropriate. For adolescents this should include individual family sessions at least one (1) time each week, unless clinically contraindicated; AND
  6. If a behavioral health diagnosis is present requiring active treatment or the facility is providing dual diagnosis services, qualified physician visits are documented as necessary; AND
  7. All therapeutic services are provided by licensed or certified professionals in accordance with state requirements; AND
  8. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered Individuals will be prepared to receive the majority of their rehabilitation in a community setting; AND
  9. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed; AND
  10. The Covered Individual resides in a community setting while receiving partial hospitalization services and is not in a 24-hour residential treatment setting; AND
  11. Treatment would include the following at least once a day and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy, and activity group therapy.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress toward treatment goals is being documented, as shown by continued participation, abstinence, and adherence to treatment recommendations, and if no progress noted or relapse occurs, the treatment plan is re-evaluated and amended such that progress will be likely.  

Not Medically Necessary:

Partial hospitalization program is considered not medically necessary when the above criteria are not met.

 

Intensive Structured Outpatient Program (IOP)

Medically Necessary:

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Substance Abuse and/or Dependence diagnosis for intensive structured outpatient program (IOP) treatment. Co-morbid psychiatric conditions frequently occur and should be assessed upon admission. All services must meet the definition of medical necessity in the Covered Individual's plan document. IOP level of care may be appropriate for the first attempt at rehabilitation. The structure and educational benefits of this level of care compared to individual outpatient may lead to better outcomes for certain Covered Individuals.

Severity of Illness (SI)

Must meet all of the following to qualify:

  1. The pattern of substance use and behavior is unlikely to change with outpatient treatment and community resources alone. However, the Covered Individual is able to live safely in the community with adequate functioning; AND
  2. There is evidence that the Covered Individual is motivated, as evidenced by an expression of an interest or desire to work towards the goals of treatment and recovery at the time of admission or shortly thereafter; AND
  3. The Covered Individual's social system and significant others are supportive of recovery, and the Covered Individual demonstrates the motivation, social and cognitive skills to develop a sober support system.

Intensity of Service (IS)

Must have all of the following to qualify: 

  1. Meets a minimum of three (3) days per week at least three (3) hours per day; the frequency may be decreased as clinically indicated; AND
  2. Programming provided will be consistent with the Covered Individual's language, cognitive, speech and/or hearing abilities; AND
  3. Implementation of individualized, problem-focused treatment plan which includes, but is not limited to:
    1. Completion of personal substance abuse history with acknowledgment of consequences of use.
    2. Initiation or continuation of relapse/recovery program with identification of relapse triggers.
    3. Attendance at community-based recovery programs - to be attended at least three (3) times per week.
    4. Drug screens as clinically appropriate and at random and an intervention plan to address drug use while in treatment.
    5. Family program and involvement in treatment as appropriate. For adolescents, at least one time each week, unless clinically contraindicated.
    6. The program has provisions for Covered Individual to access psychiatric treatment for a dual diagnosis, as needed AND
  4. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans; AND
  5. All therapeutic services are provided by licensed or certified professionals in accordance with state requirements; AND
  6. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented ; AND
  7. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered Individuals will be prepared to receive the majority of their rehabilitation in a community setting; AND
  8. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed; AND
  9. The Covered Individual resides in a community setting while receiving intensive outpatient program services and is not in a 24-hour residential treatment setting.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress toward treatment goals is being documented, as shown by continued participation, abstinence, and adherence to treatment recommendations, and if no progress noted or relapse occurs, the treatment plan is re-evaluated and amended such that progress will be likely.

Not Medically Necessary:

Intensive structured outpatient program is considered not medically necessary when the above criteria are not met.

 

Outpatient Treatment

Medically Necessary:

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Substance Abuse and/or Dependence diagnosis for outpatient treatment. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. Substance use is excessive, maladaptive and some symptoms have persisted for at least one (1) month or have occurred as part of a repeated pattern over a longer period of time; AND
  2. There is evidence that the Covered Individual is motivated as evidenced by expression of an interest or desire to work towards the goals of treatment recovery or can be motivated; AND
  3. Covered Individual's social system and significant others are supportive of recovery, or Covered Individual demonstrates the social and cognitive skills to develop a sober support system; AND
  4. Covered Individual does not meet the criteria for a higher level of care.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Frequency:
    1. Initial: Up to a maximum of six (6) therapy sessions within the first three (3) week period. For adolescents, this should also include one (1) family session per week.
    2. Ongoing: Short term problem focused therapy in conjunction with community based programs and frequency of visits should be decreased over time to generally less than one time per week; AND
  2. Documentation of complete drug and alcohol assessment; AND
  3. Assessment of family and social support system; AND
  4. Individual treatment plan which includes:
    1. Identification of recovery goals.
    2. Issues such as mental preoccupation with alcohol or drug use, cravings, peer pressure, lifestyle, consequences of use, and attitudinal changes are addressed.
    3. Development of a relapse prevention plan and sober support system.
    4. Monitoring attendance at community-based recovery programs.
    5. Utilization of educational materials (books, videos).
    6. Drug screens as clinically appropriate (may require coordination with a physician).
    7. Development of a discharge/aftercare plan.
    8. Referred to psychiatric services for a dual diagnosis, as needed; AND
  5. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  6. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress toward treatment goals is being documented, as shown by continued participation, abstinence, and adherence to treatment recommendations, and if no progress noted or relapse occurs, the treatment plan is re-evaluated and amended such that progress will be likely.

Not Medically Necessary:

Outpatient treatment is considered not medically necessary when the above criteria are not met.

 

Substance Abuse Outpatient Detoxification with Extended On-site Monitoring

Medically Necessary:

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Substance Dependence diagnosis for substance abuse outpatient detoxification with extended on-site monitoring treatment. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must meet either 1 or 2, and also meet 3 and 4:

  1. Nature and pattern of use of abused substance requires gradual, medically supervised outpatient withdrawal to prevent complications that cannot be managed outside of a structured treatment setting, but do not require 24-hour medical monitoring. (Withdrawal from amphetamine/cocaine and marijuana, unless accompanied by psychosis, do not generally require a medical detoxification), OR
  2. Presence of moderate withdrawal symptoms that cannot be managed outside of a daily structured treatment setting; but do not require 24-hour medical monitoring. Adequate arrangements can be made for treatment of withdrawal symptoms during the times that the program does not meet.
    1. For alcohol, opioids and sedative-hypnotics:
      1. The Covered Individual is experiencing signs and symptoms of withdrawal such as abnormal vital signs, and evidence of physical discomfort or cravings that make it unlikely that the Covered Individual would be able to abstain long enough to withdraw without a structured treatment setting.
      2. Withdrawal symptoms have responded to, or are likely to respond to, normal therapeutic doses of benzodiazepines, opiates or sedative-hypnotics in the therapeutic range AND
      3. The risk of seizures, hallucinations, dissociation or severe affective disturbances during unobserved periods is assessed to be minimal.
      4. The abstinence syndrome can be stabilized at the end of each day's monitoring so that the Covered Individual can manage such symptoms at home with appropriate supervision.
    2. For stimulants, the Covered Individual who is withdrawing from stimulants and is experiencing significant lethargy, agitation, paranoia, stimulant-induced psychotic symptoms or severe depression, and requires extended outpatient monitoring to assess impulse control and readiness for substance abuse rehab treatment or the need for psychiatric hospitalization to address psychotic symptoms. (NOTE: This assessment and referral to another level of care should be completed within one treatment day).
      AND
  3. Must meet all of the following to qualify.Failure to meet these would suggest that a higher level of care such as sub-acute/ residential or acute inpatient detoxification is required:
    1. Absence of a complicating psychiatric illness that requires inpatient or residential treatment.
    2. Absence of a withdrawal history of delirium tremens, seizures, hallucinations or acute psychotic reaction secondary to chronic substance use.
    3. Absence of an unstable medical illness that requires 24-hour medically-supervised monitoring during withdrawal.
    4. If the sedative-hypnotic withdrawal is being treated, there is no comorbid substance withdrawal from alcohol, opiates or stimulants.
    5. Severe withdrawal symptoms outside normal program hours are assessed to be unlikely.
      AND                                                                                                                                                                                      
  4. A well-defined clinical rationale is documented that explains why Covered Individual would not be a reasonable candidate for office-based outpatient management of withdrawal symptoms, along with community supports.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Detoxification is conducted in a medical facility (i.e. hospital or medical clinic) to determine the need for more or less intensive detoxification services. The detoxification is conducted in a facility that is fully integrated with intensive outpatient or partial hospital substance abuse rehabilitation services; AND
  2. Documentation of blood and/or urine drug screen results upon admission and as clinically indicated; AND
  3. Multi-disciplinary problem-focused treatment plan that addresses psychological, social (including living situation and support system), medical, substance abuse and rehabilitation needs; AND
  4. Examination by a physician, (or physician extender or independently licensed clinician as allowed by law or health plan benefits), upon admission and ready availability of a physician for consultation on a daily basis while in detoxification; AND
  5. An addiction-focused history obtained as part of the initial assessment and reviewed by the physician during the admission process; AND
  6. At least 3 hour skilled nursing (either an RN or LVN) on site with availability during all hours of program operation. [Note If the Covered Individual's medical symptoms require 24-hour nursing care for assessment, frequent administration of medication, monitoring of vital signs and other services only provided by a nurse, then acute inpatient detoxification is required]; AND
  7. Medication management of withdrawal symptoms, with all controlled substances used for detoxification administered by persons appropriately licensed to dispense controlled substances; AND
  8. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans; AND
  9. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  10. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress toward treatment goals is being documented, as shown by continued participation, abstinence, and adherence to treatment recommendations, and if no progress noted or relapse occurs, the treatment plan is re-evaluated and amended such that progress will be likely.

Not Medically Necessary:

Substance abuse outpatient detoxification with extended on-site monitoring is considered not medically necessary when the above criteria are not met.

 

Substance Abuse Outpatient Detoxification Without Extended On-site Monitoring

Medically Necessary:

To qualify, Covered Individual's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Substance Dependence diagnosis for substance abuse outpatient detoxification without extended on-site monitoring (office based) treatment. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must meet either 1 or 2, and also meet 3 and 4:

  1. Nature and pattern of use of abused substance requires gradual, medically supervised outpatient withdrawal to prevent complications, and the severity of anticipated withdrawal does not require a structured treatment setting (Withdrawal from amphetamine/cocaine and marijuana, unless accompanied by psychosis, do not generally require a medical detoxification), OR
  2. Presence of mild to moderate withdrawal symptoms that can be managed outside of a structured treatment setting, meeting one of the following:
    1. For alcohol, mild withdrawal symptoms (as evidenced by a CIWA-Ar score of 8 or less or the equivalent on a comparable standardized scoring system).
    2. For sedative-hypnotics:
      1. Any recent use is confined to therapeutic or near-therapeutic dosages; AND
      2. Sedative hypnotic use is not complicated by daily use of alcohol or other drugs known to produce a significant withdrawal syndrome.
    3. For opioids without using opioid substitution methods of detoxification (Must meet either i or ii, and also meet  iii):
      1. Either the Covered Individual's use of high-potency opioids (such as injectable or smoked forms) has not been daily for more than two (2) weeks prior to initiation of treatment, or the use of high-potency opioids is at or near the therapeutically  recommended level, OR
      2.  There has been no repetitive use in the past two (2) weeks of injectable or smoked forms of opioids, AND
      3. Absence of significantly unstable vital signs or severe withdrawal symptoms that meet criteria for a higher level of care.
    4. For opioids with use of opioid substitution methods of detoxification:
      1. Absence of significantly unstable vital signs or severe withdrawal symptoms that meet criteria for a higher level of care.
    5. For stimulants, the Covered Individual is withdrawing from stimulants and is experiencing significant lethargy, agitation, paranoia, mild psychotic symptoms or moderate depression, but has good impulse control.
      AND        
  3. Must meet all of the following to qualify. Failure to meet these would suggest that a higher level of care such as sub-acute/ residential or acute inpatient detoxification is required:
    1. Absence of a complicating psychiatric illness that requires inpatient or residential treatment; AND
    2. Absence of a withdrawal history of delirium tremens, seizures, hallucinations or acute psychotic reaction secondary to chronic substance use; AND
    3. Absence of an unstable medical illness that requires 24-hour medically-supervised monitoring during withdrawal AND
    4. Withdrawal from sedative-hypnotics is not generally of concern but may be problematic if there is concurrent use of stimulants; AND
    5. Severe withdrawal symptoms between visits are assessed to be unlikely AND
  4. The Covered Individual is assessed as likely to complete needed detoxification and to enter into continued treatment or self-help recovery, including the Covered Individual's expression of an interest or desire to work towards the goals of treatment and recovery (or, for children and adolescents, a family support system likely to ensure continued treatment).

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Detoxification takes place in a health care facility such as a physician's office, hospital outpatient department, mental health treatment facility or addiction treatment facility; AND
  2. The withdrawal is managed by a physician, who assesses the Covered Individual each day that detoxification services are provided, and who provides for 24-hour emergency coverage during detoxification.
    1. In cases of opioid substitution methods of detoxification, the withdrawal is managed by a physician authorized by the Drug Enforcement Administration (DEA) to use opioids for detoxification; AND
  3. The physician has the training and skills to conduct psychosocial substance abuse rehabilitation treatment, or has ready access other licensed or certified professionals who have such qualifications; AND
  4. A comprehensive medical history and physical examination by a physician upon initiation of treatment; AND
  5. An addiction-focused history obtained as part of the initial assessment and reviewed by the physician during the admission process; AND
  6. Appropriate laboratory and toxicology tests are performed; AND
  7. Problem-focused treatment plan that addresses psychological, social (including living situation and support system), medical, substance abuse and rehabilitation needs; AND
  8. Daily assessment of progress during detoxification and any treatment changes (or less frequent if the severity of withdrawal is documented to be sufficiently mild or stable); AND
  9. Discharge/aftercare planning is initiated on the day of admission and includes appropriate continuing care plans and referral arrangements as needed; AND
  10. Coordination of care with other clinicians providing care to the Covered Individual or family members, including psychiatrist/therapist and PCP is documented; AND
  11. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress toward treatment goals is being documented, as shown by continued participation, abstinence, and adherence to treatment recommendations, and if no progress noted or relapse occurs, the treatment plan is re-evaluated and amended such that progress will be likely.

Not Medically Necessary:

Substance abuse outpatient detoxification without extended on-site monitoring is considered not medically necessary when the above criteria are not met.

 

Outpatient (Office Based) Medication Assisted Treatment (MAT) of Opioid Dependence

Medically Necessary:

To qualify, Covered Individual must meet the diagnostic criteria for a DSM diagnosis of Opioid Dependence for substance abuse outpatient (office based) medication assisted treatment (MAT) of opioid dependence treatment.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. There is a reasonable expectation of compliance; AND
  2. There is evidence that the Covered Individual has restorative potential. This will be demonstrated in part, although not limited to, Covered Individual's expression of an interest or desire to work towards the goals of treatment and recovery, including abstinence from all illicit substance use and all opioid use; AND
  3. Covered Individual's social system and significant others are supportive of recovery, or Covered Individual demonstrates the social and cognitive skills to develop a sober support system; AND
  4. There is documentation of the absence of current, active untreated use of alcohol, sedative-hypnotics or other central nervous system depressants; AND
  5. If the Covered Individual is pregnant, the obstetrician or other provider managing the pregnancy has been consulted and concurs with the treatment plan before MAT is initiated; AND
  6. The Covered Individual is not acutely psychotic, imminently suicidal, or imminently homicidal; AND
  7. The Covered Individual gives permission for free exchange of clinical information among all health care providers, including pharmacists.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Treatment conforms to the requirements of The Drug Addiction Treatment Act of 2000 (DATA 2000) and all related Federal and State regulations.
    1. MAT is managed by a physician who has been granted a waiver from the special registration requirements in the Controlled Substances Act to provide opioid addiction therapy with approved Schedule III, IV, or V narcotics.
    2. Only approved Schedule III, IV, or V narcotics are utilized; no Schedule II narcotics are utilized; AND
  2. The physician assesses the Covered Individual face-to-face on each day that MAT services are provided, and provides for 24-hour emergency coverage during MAT; AND
  3. Face-to-face assessment at least monthly by the prescribing physician; AND
  4. Psychiatric consultation is completed within the first 30 days for any Covered Individual with a DSM diagnosis which may interfere with recovery; AND
  5. Coordination of care among all prescribing providers; AND
  6. Coordination of care with mental health and substance abuse recovery providers occurs in a timely manner; AND
  7. Assessment of family and social support system occurs within the first week of treatment; AND
  8. Individual treatment plan which includes:
    1. Psychosocial components of treatment by licensed or certified substance abuse and/or behavioral health providers at intervals appropriate to the stage of recovery. The psychosocial component of treatment may also be provided by a physician who has the appropriate training and experience to provide such treatment.
    2. Management of impediments to recovery including interpersonal, legal, financial and housing.
    3. Tapering of MAT in a manner that is medically appropriate for discontinuation of all opioids (unless treatment is for maintenance).
    4. Monitoring attendance at community-based recovery programs.
    5. Utilization of educational materials (books, videos).
    6. Monitoring of adherence using drug screening, pill counts or both. 
    7. Development of a discharge/aftercare plan.
    8. Referral to psychiatric services for a dual diagnosis, as needed. 
      AND
  9. Evaluation for medication that may improve the member's ability to remain abstinent; document the rationale if no medication is prescribed.

Continued Stay Criteria (CS)

NOTE:   Relapse is considered an integral part of the disease concept and does not singularly constitute treatment failure or need for a higher level of care.

Must continue to meet "SI/IS" Criteria and have all of the following to qualify:

  1. Progress toward treatment goals is being documented (see "IS"); AND
  2. Treatment plan is being re-evaluated and amended in a timely and medically appropriate manner; AND
  3. Covered Individual continues to regularly attend community-based recovery programs until sustained abstinence is demonstrated; AND
  4. Covered Individual continues to show motivation for abstinence and recovery, is accepting responsibility, and is gaining insight; AND
  5. Covered Individual is maintaining sobriety or showing progress toward maintaining sobriety for the first 6 months of MAT; AND
  6. Covered Individual is maintaining sobriety after the first 6 months of MAT.

Not Medically Necessary:

Outpatient (Office Based) medication assisted treatment (MAT) of opioid dependence is considered not medically necessary when the above criteria are not met.

Coding

Coding edits for medical necessity review are not implemented for this guideline.  Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

Substance abuse treatment should not be primarily for the avoidance of incarceration of the Covered Individual or to satisfy a programmatic length of stay (refers to a pre-determined number of days or visits for a program's length instead of an individualized determination of how long a member needs to be in that program). There should be a reasonable expectation that the Covered Individual's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the Covered Individual's illness.

It is noted that there is variation in the availability of services in different geographic and regional areas. If an indicated service is not available within a Covered Individual's community at the level of service indicated by the criteria, authorization may be given for those services at the next highest available level.

In some geographical areas, state regulations allow non-physicians to treat Covered Individuals at inpatient facilities. In these guidelines, such non-physicians with prescriptive authority who are operating within the scope of their license may be substituted where the criteria specifies a physician.

Definitions

Acute Inpatient Hospitalization: Acute inpatient psychiatric hospitalization is defined as treatment in a hospital psychiatric unit that includes 24-hour nursing and daily active treatment under the direction of a psychiatrist and certified by The Joint Commission or the National Integrated Accreditation for Healthcare Organizations (NIAHO) as a hospital. Acute psychiatric treatment is appropriate in an inpatient setting when required to stabilize Covered Individuals who are in acute distress and return them to a level of functioning in which a lesser level of intense treatment can be provided. A need for acute inpatient care occurs when the Covered Individual requires 24-hour nursing care, close observation, assessment, treatment and a structured therapeutic environment that is available only in an acute inpatient setting.

Residential Treatment: Residential treatment is defined as specialized treatment that occurs in a residential treatment center. Residential treatment is 24 hours per day and requires a minimum of one physician visit per week in a facility based setting. Wilderness programs are not considered residential treatment programs.

Partial Hospitalization: Partial hospitalization (sometimes called day treatment) is a structured, short-term treatment modality that offers nursing care and active treatment in a program that is operable at a minimum of six (6) hours per day, five (5) days per week. Covered Individuals must attend a minimum of 6 hours per day when participating in a partial hospitalization program. Covered Individuals are not cared for on a 24-hour per day basis, and typically leave the program each evening and/or weekends. Partial hospitalization treatment is provided by a multidisciplinary treatment team, which includes a psychiatrist. Partial hospitalization is an alternative to acute inpatient hospital care and offers intensive, coordinated, multidisciplinary clinical services for Covered Individuals that are able to function in the community at a minimally appropriate level and do not present an imminent potential for harm to themselves or others.

Intensive Outpatient Treatment: Intensive outpatient is a structured, short-term treatment modality that provides a combination of individual, group and family therapy. Intensive outpatient programs meet at least three times per week, providing a minimum of three (3) hours of treatment per session. Intensive outpatient programs must be supervised by a licensed mental health professional. Intensive outpatient treatment is an alternative to inpatient or partial hospital care and offers intensive, coordinated, multidisciplinary services for Covered Individuals with an active psychiatric or substance related illness who are able to function in the community at a minimally appropriate level and present no imminent potential for harm to themselves or others.

Outpatient Treatment: Outpatient treatment is a level of care in which a mental health professional licensed to practice independently provides care to individuals in an outpatient setting, whether to the Covered Individual individually, in family therapy, or in a group modality.

References

Peer Reviewed Publications:

  1. Kahn, DA, Carpenter D, Docherty JP, Frances A. (1996): The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry, 57 (Suppl 12A).
  2. McEvoy JP, Scheifler PL, Frances A. Treatment of schizophrenia 1999. The expert consensus guideline series. J Clin Psychiatry. 1999; 60 Suppl 11:3-80.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American Academy of Child & Adolescent Psychiatry. Practice Parameters. Available at: http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters. Accessed on January 13, 2014.
  2. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on January 13, 2014.
  3. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on January 13, 2014.
  4. Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.
  5. Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 07-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
  6. Depression in Primary Care: Detection and Diagnosis. Volume 1. Detection and Diagnosis Clinical Guideline Number 5. AHCPR Publication No. 93-0550: April 1993.
  7. Fishman MJ, Shulman GD, Mee-Lee D, et al. ASAM patient placement criteria: supplement on pharmacotherapies for alcohol use disorders. 1st ed. Philadelphia: Lippincott Williams & Wilkins. 2010.
  8. Hoffman NG, Mee-Lee D, Halikas JA. Patient placement criteria for the treatment of psychoactive substance use disorders. Chevy Chase: American Society of Addiction Medicine. 2001.
  9. Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
  10. Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
  11. Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. Intensive outpatient treatment for alcohol and other drug abuse. 1994. DHHS Publication No. (SMA) 94B2077.
  12. Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
  13. Weiner RD. Manual of psychiatric quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992. Electroconvulsive therapy guidelines and criteria.
  14. Weiner RD. Practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (A task force report of the American Psychiatric Association). 2nd ed. Arlington: American Psychiatric Publishing. 2001.
Index

Detoxification
Inpatient acute detoxification
Intensive structured outpatient program (IOP)
Medication assisted treatment (MAT)
On-site monitoring (office based)
Opioid Dependence
Outpatient detoxification
Outpatient treatment
Partial hospitalization program (PHP)
Residential Treatment Detoxification
Residential Treatment Center (RTC)

History

Status

Date

Action

Revised02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised02/07/2014Behavioral Health Subcommittee review. Removed indications of Axis from Clinical Indications.
New08/08/2013MPTAC review.
New07/26/2013Behavioral Health Subcommittee review. Initial document development. Clarification to Clinical Indications Partial Hospitalization Program, Intensity of Service. Updated References. The Behavioral Health Medical Necessity Criteria effective January 1, 2013 was split apart into specific subject matter clinical UM guidelines.