Clinical UM Guideline


Subject:  Substance-Related and Addictive Disorder Treatment
Guideline #:  CG-BEH-04Current Effective Date:  10/14/2014
Status:RevisedLast Review Date:  08/14/2014

Description

This document addresses the treatment and appropriate levels of care for substance-related disorders. The medical necessity criteria outlined in this document for each level of care relating to substance-related disorder treatment includes three categories; Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria includes descriptions of the member'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-related disorder treatment for:

Note: Please see the following related documents for additional information:

Clinical Indications

Inpatient Acute Withdrawal (Detoxification)

Medically Necessary:

To qualify, member'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-related withdrawal diagnosis for inpatient acute withdrawal (detoxification) treatment.

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 for example, alcohol and benzodiazepine withdrawal (note: withdrawal from stimulants or marijuana alone generally does not require a medical withdrawal [detoxification] and opiate withdrawal [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 for example, tremors, unstable vital signs, diaphoresis, gastrointestinal (GI) disturbances, agitation, withdrawal hallucinations, confusion or disorientation or seizures.

Note: Members who experience severe psychological withdrawal symptoms may require 24-hour care, even though they do not meet the withdrawal (detoxification) criteria. Please refer to treatment (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 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 member'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 member's primary care physician (PCP), providing treatment to the member, 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 member is not stable enough to be treated at a lower level of care.

Not Medically Necessary:

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

 

Inpatient Acute Treatment (Rehabilitation)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD substance-related use disorder diagnosis for inpatient acute treatment (rehabilitation).

Severity of Illness (SI)
Must have all of the following to qualify:

  1. Member no longer meets withdrawal (detoxification) SI criteria; AND
  2. Member has a severe co-morbid medical or psychiatric disorder, which requires 24-hour acute hospital care; AND
  3. Substance-related disorder is severe based on the presence of six or more current symptoms of a substance use disorder for at least one substance use disorder condition; AND
  4. The member 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 days a week; AND
  3. Programming provided will be consistent with the member'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 member 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 member's PCP, providing treatment to the member, 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 member 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 treatment (rehabilitation) is considered not medically necessary when the above criteria are not met.

 

Residential Treatment Withdrawal (Detoxification)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD substance-related withdrawal diagnosis for residential treatment withdrawal (detoxification).

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 for example, alcohol and benzodiazepine withdrawal (note: withdrawal from stimulants or marijuana alone generally does not require a medical withdrawal [detoxification] and opiate withdrawal [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 treatment (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 withdrawal (detoxification); AND
  4. Eight hour skilled nursing (either an RN or LVN/LPN) on site with 24-hour availability. [Note: If the member'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 withdrawal (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 member's PCP, providing treatment to the member, 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 member is not stable enough to be treated at a lower level of care.

Not Medically Necessary:

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

 

Residential Treatment Center (RTC)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD substance-related use disorder diagnosis for residential treatment center treatment.

Severity of Illness (SI)
Must meet criteria 1 or 2, as well as 3 to qualify:

  1. Acute psychiatric symptoms that:
    1. Include either self-injurious or risk-taking behaviors that pose a risk of serious harm to the member and/or others and cannot be managed outside of a 24 hour structured setting; AND
    2. Interfere with maintaining abstinence; 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 member or others and cannot be managed outside of a 24 hour structured setting; OR
  2. Acute medical symptoms that would likely interfere with the member maintaining abstinence and recovery outside of a 24 hour structured setting; AND
  3. Substance-related disorder is moderate or severe based on the presence of four or more current symptoms of a substance use disorder for at least one substance use disorder condition; AND

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 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 member's language, cognitive, speech and/or hearing abilities; AND
  4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the member's PCP, providing treatment to the member, 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 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 members will be prepared to receive the majority of their treatment (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 member 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, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD substance-related use disorder diagnosis for partial hospitalization program (PHP) treatment. Co-morbid psychiatric conditions frequently occur and should be assessed upon admission.

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 hours duration a day; AND
  2. Substance-related disorder is moderate or severe based on the presence of four or more current symptoms of a substance use disorder for at least one substance use disorder condition; AND
  3. The member 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 member at a lower level of care; AND
  5. The member 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 hours a day (unless defined differently by local state law). The frequency of attendance per week may vary according to clinical needs and progress, a minimum number of times per week four or five times per week; 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 member's language, cognitive, speech and/or hearing abilities; AND
  4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the member's PCP, providing treatment to the member at least one time a week, 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 member'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 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 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 members will be prepared to receive the majority of their treatment (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 member 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, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD substance-related use disorder diagnosis for IOP treatment. Co-morbid psychiatric conditions frequently occur and should be assessed upon admission. IOP level of care may be appropriate for the first attempt at treatment (rehabilitation). The structure and educational benefits of this level of care compared to individual outpatient may lead to better outcomes for certain members.

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 member is able to live safely in the community with adequate functioning; AND
  2. There is evidence that the member 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 member's social system and significant others are supportive of recovery, and the member 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. Treatment services offered at least three treatment hours per day at least three times per week; AND
  2. Programming provided will be consistent with the member'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 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 member 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 member's PCP, providing treatment to the member, 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 members will be prepared to receive the majority of their treatment (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 member 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, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD substance-related use disorder diagnosis for outpatient treatment.

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 month or have occurred as part of a repeated pattern over a longer period of time; AND
  2. There is evidence that the member 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. Member's social system and significant others are supportive of recovery, or member demonstrates the social and cognitive skills to develop a sober support system; AND
  4. Member 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 therapy sessions within the first three week period. For adolescents, this should also include one 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 member's PCP, providing treatment to the member, 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-Related Outpatient Withdrawal (Detoxification) with Extended On-site Monitoring

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD substance-related withdrawal diagnosis for outpatient withdrawal (detoxification) with extended on-site monitoring treatment.

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 withdrawal [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 member 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 member 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 member can manage such symptoms at home with appropriate supervision.
    2. For stimulants, the member 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 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 withdrawal (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 member 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. Withdrawal (detoxification) is conducted in a medical facility (that is, hospital or medical clinic) to determine the need for more or less intensive withdrawal (detoxification) services. The withdrawal (detoxification) is conducted in a facility that is fully integrated with intensive outpatient or partial hospital substance abuse treatment (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 treatment (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 withdrawal (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 three hour skilled nursing (either an RN or LVN) on site with availability during all hours of program operation. [Note If the member'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 withdrawal (detoxification) is required]; AND
  7. Medication management of withdrawal symptoms, with all controlled substances used for withdrawal (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 member's PCP, providing treatment to the member, 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-related outpatient withdrawal (detoxification) with extended on-site monitoring is considered not medically necessary when the above criteria are not met.

 

Substance-Related Outpatient Withdrawal (Detoxification) Without Extended On-site Monitoring

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD substance-related withdrawal diagnosis for outpatient withdrawal (detoxification) without extended on-site monitoring (office based) treatment.

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 withdrawal [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 withdrawal (detoxification) (Must meet either i or ii, and also meet  iii):
      1. Either the member's use of high-potency opioids (such as injectable or smoked forms) has not been daily for more than two 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 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 withdrawal (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 member 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 withdrawal (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 member has an understanding of withdrawal management and has expressed a commitment to enter into treatment, has adequate support services to ensure a commitment to complete the withdrawal management, or is willing to accept a recommendation for treatment.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Withdrawal (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 member each day that withdrawal (detoxification) services are provided, and who provides for 24-hour emergency coverage during withdrawal (detoxification).
    1. In cases of opioid substitution methods of withdrawal (detoxification), the withdrawal is managed by a physician authorized by the Drug Enforcement Administration (DEA) to use opioids for withdrawal (detoxification); AND
  3. The physician has the training and skills to conduct psychosocial substance abuse treatment (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 treatment (rehabilitation) needs; AND
  8. Daily assessment of progress during withdrawal (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 member 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-related outpatient withdrawal (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 Use Disorder

Medically Necessary:

To qualify, member must meet the diagnostic criteria for a DSM or ICD diagnosis of opioid use disorder.

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 member has restorative potential. This will be demonstrated in part, although not limited to, member'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. member's social system and significant others are supportive of recovery, or member 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 member 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 member is not acutely psychotic, imminently suicidal, or imminently homicidal; AND
  7. The member 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 Federal regulations such as The Drug Addiction Treatment Act of 2000 (DATA 2000).
    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 indicated Schedule II, III, IV, or V narcotics are utilized; AND
  2. The physician assesses the member 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 member 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. Member continues to regularly attend community-based recovery programs until sustained abstinence is demonstrated; AND
  4. Member continues to show motivation for abstinence and recovery, is accepting responsibility, and is gaining insight; AND
  5. Member is maintaining sobriety or showing progress toward maintaining sobriety for the first six months of MAT; AND
  6. Member is maintaining sobriety after the first six 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

The illnesses associated with substance-related and addictive disorder treatment can be roughly grouped into intoxication, withdrawal and rehabilitation. Intoxication with a substance like alcohol can be lethal, perhaps especially at first exposure, and often complicates medical and behavioral health treatment for other conditions (trauma and depression are examples). For most addictive substances, intoxication is relatively brief (lasting hours). Management of withdrawal and treatment of substance related disorders are the reasons that members seek the types of care covered in this guideline.  

The management of withdrawal syndromes, also referred to as detoxification, depends in part on the type of substance. The duration and intensity of use also contribute. Concomitant medical conditions, often reflecting the impact of the substance used, are another factor in the type of care needed. Alcohol withdrawal is the most common and, arguably, most varied type of withdrawal syndrome. In the most severe instances, associated with the well-known medical term delirium tremens, intensive care unit (ICU) treatment with life support measures and management of psychosis is required. This type of medical treatment falls under the expertise of medical practitioners who manage care in ICUs and is outside the realm of this guideline. At the other end of the spectrum of severity, mild alcohol withdrawal can be managed with office care in supportive outpatient settings.

Treatment of addiction, also often referred to as rehabilitation, can also be provided in a wide variety of settings. Many treatment settings incorporate community resources in the patient-centered care plan; at least some individuals use community resources as the sole means of addressing addiction. For some individuals, starting treatment for a substance-related disorder requires the restrictive environment of the hospital to manage serious psychiatric symptoms like suicidality or poorly controlled medical conditions like diabetes. 

Diagnosis of substance-related and addictive disorders is principally based on American Psychiatric Association criteria (DMS-5). The American Society of Addiction Medicine (ASAM) provides extensive guidance on the use of treatment resources to manage substance related withdrawal and addiction treatment. 

Substance-related disorder treatment should not be primarily for the avoidance of incarceration of the member 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 member's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the member'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 member'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 members at inpatient facilities. In these documents, 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 members 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 member 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 hours per day, five days per week. Members must attend a minimum of six hours per day when participating in a partial hospitalization program. Members 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 members 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 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 members 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 member individually, in family therapy, or in a group modality.

References

Peer Reviewed Publications:

  1. Frances A Docherty JP, Kahn DA. The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry. 1996; 5(Suppl 12A):1-88.
  2. 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 June 5, 2014.
  2. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on June 5, 2014.
  3. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on June 5, 2014.
  4. Association for Ambulatory Behavioral Healthcare. Standards and Guidelines. Available at: https://www.bpsys.org/aabh.html. Accessed on July 8, 2014.
  5. 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.
  6. 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.
  7. Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
Index

Detoxification
Inpatient acute withdrawal (detoxification)
Intensive structured outpatient program (IOP)
Medication assisted treatment (MAT)
On-site monitoring (office based)
Outpatient treatment
Outpatient withdrawal (detoxification)
Partial hospitalization program (PHP)
Residential treatment withdrawal (detoxification)
Residential treatment center (RTC)
Withdrawal

History

Status

Date

Action

Revised08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised08/08/2014Behavioral Health Subcommittee review. Title change to "Substance-Related and Addictive Disorder Treatment." Updated Description, Discussion/General Information, References, and Index. Multiple changes to the Clinical Indications.
Revised02/13/2014MPTAC 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.