Sei sulla pagina 1di 17
COVERAGE DETERMINATION GUIDELINE

COVERAGE DETERMINATION GUIDELINE

Inpatient Detoxification of Substance Use Disorders

Guideline Number: BHCDG082011

Approval Date: September, 2010

Revised Date: December, 2011

Table of Contents:

Instructions for Use

1

Plan Document Language

2

Indications for Coverage

2

Coverage Limitations and Exclusions

13

Definitions

14

References

14

Coding

16

Product:

2001

Generic UnitedHealthcare COC/SPD

2007

Generic UnitedHealthcare COC/SPD

2009

Generic UnitedHealthcare COC/SPD

May also be applicable to other health plans and products

Related Coverage Determination Guidelines:

Custodial Care Coverage Determination Guideline, 2011

Judicial or Administrative Proceedings or Orders

Related Medical Policies:

Level of Care Guidelines

Clinical Practice Guideline, VA/DoD Evidenced Based Practice, Management of Substance Use Disorders, 2009

ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition, Revised 2001

American Academy of Child and Adolescent Psychiatry, Practice Parameter for the Assessment and Treatment of Children and

Adolescents with Substance Use Disorders,

2007

American Psychiatric Association, Practice Guideline for the Treatment of Patients with Substance Use Disorders, 2006

American Psychiatric Association, Practice

Guideline for the Treatment of Patients with Substance Use Disorders, Guideline Watch

2007

INSTRUCTIONS FOR USE

This Coverage Determination Guideline provides assistance in interpreting behavioral health benefit plans that are managed by United Behavioral Health. This Coverage Determination Guideline is also applicable to behavioral health benefit plans managed by Pacificare Behavioral Health, OptumHealth Behavioral Solutions, or U.S. Behavioral Health Plan, California.

Inpatient Detoxification of Substance Use Disorders

Page 1 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee’s document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or Summary Plan Descriptions (SPDs)) may differ greatly from the standard benefit plans upon which this guideline is based. In the event that the requested service or procedure is limited or excluded from the benefit, is defined differently, or there is otherwise a conflict between this document and the COC/SPD, the enrollee's specific benefit document supersedes these guidelines.

All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements that supersede the COC/SPD and the plan benefit coverage prior to use of this guideline. Other coverage determination guidelines and clinical guideline may apply.

United Behavioral Health reserves the right, in its sole discretion, to modify its coverage determination guidelines and clinical guidelines as necessary.

While this Coverage Determination Guideline does reflect United Behavioral Health’s understanding of current best practices in care, it does not constitute medical advice.

PLAN DOCUMENT LANGUAGE

Before using this guideline, please check enrollee’s specific plan document and any federal or state mandates, if applicable.

INDICATIONS FOR COVERAGE

Key Points

According to the DSM, Substance Dependence Disorders are characterized by a maladaptive pattern of substance use, leading to clinically significant impairment or distress as manifested by three or more of the following symptoms occurring at any time within the same 12-month period:

o

Increase in tolerance and/or diminished effect of substance

o

Symptoms of withdrawal

o

Increases in amount of use

o

A desire and failure to control substance use

o

Spending a great deal of time in substance related activities

o

Important social, interpersonal and occupational activities are neglected and

o

A known physical or mental condition has worsened with the continued use of substances

United Behavioral Health maintains that the treatment of Substance Dependence Disorders in an inpatient detoxification setting should be consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines.

Patients with Substance Dependence Disorders should be treated in a level of care that is most likely to prove safe and effective. Choice of Inpatient Detoxification is driven by the type of substance(s) used and the type and severity of withdrawal symptoms. Additional considerations include the following:

o

The patient is exhibiting signs and symptoms of severe withdrawal as a result of alcohol and/or drug use, requiring hourly monitoring and 24-hour medical management.

o

The patient’s Clinical Institute Withdrawal Assessment Scale (CIWA-Ar) score is at

Inpatient Detoxification of Substance Use Disorders

Page 2 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

least 10.

o

The patient requires hourly monitoring due to the administration of intravenous medication or infusions, high levels of agitation or confusion, or extreme vital signs due to withdrawal.

o

The patient is experiencing or is likely to experience seizures, delirium tremens, or severe persistent hallucinations due to withdrawal.

o

The patient is experiencing severe opiate withdrawal that cannot be stabilized or managed at a less intensive level of care.

o

Intoxication and/or withdrawal due to stimulant use requiring psychiatric or medical management due to symptoms of psychosis, impulsivity or suicidality.

o

There has been recent head trauma or loss of consciousness with persistent neurological or mental status changes that requires hourly observation.

o

The patient has a medical and/or psychiatric disorder that is likely to complicate detoxification.

The goals of Inpatient Detoxification are to:

o

Safely ameliorate and stabilize acute symptoms of withdrawal,

o

Stabilize the patient’s physical condition,

o

Identify the signs and symptoms of any co-occurring medical or psychiatric disorders and,

o

Facilitate the patient’s entry into substance use disorder treatment at the next, most appropriate level of care.

Best practices within the Inpatient Detoxification setting include the following:

o

Comprehensive Assessment

Medical and psychiatric evaluations performed at admission by a physician, to include the identification of any co-occurring conditions.

o

Toxicology and Laboratory Testing

Administer applicable toxicology and laboratory tests within 24-hours of admission.

o

Treatment Plan

 

Inpatient detoxification treatment plans should be individually tailored to address the patient’s acute intoxication and withdrawal symptoms, monitor response, while updating the treatment plan as changes are observed,

The patient’s family/support network should be engaged and included in the treatment and discharge planning process, if clinically appropriate.

o

Psychiatric/Medical Interventions

Interventions should target medical, cognitive, emotional and behavioral needs with 24-hour nursing care and hourly medical monitoring and management.

o

Pharmacotherapy/Detoxification Interventions

The primary feature of detoxification in this setting includes the use of:

Medications to address intoxication and withdrawal;

Agonists and antagonists to decrease the effects of abused

Inpatient Detoxification of Substance Use Disorders

Page 3 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

substances;

Medications to address cravings; and

Medications for the treatment of co-occurring psychiatric conditions.

o Discharge and Aftercare Planning

The discharge plan is derived from the member’s response to treatment, prior history of treatment, and availability of services in the member’s community. The discharge plan should document:

The next level of care and recommended modalities of treatment;

Linkages with peer services and other community resources such as an age-appropriate organized sobriety group, accountability partner such as a sponsor, or other resources that will aid in the member’s recovery.

The plan to convey pertinent clinical information to the post- discharge provider(s);

The plan to ensure that the member has a supply of medication sufficient to bridge the time between discharge and the scheduled follow-up medication management visit; and

Confirmation that the member understands and can comply with the discharge plan.

Risk, safety and crisis management plan.

Inpatient detoxification is comprised of services that are provided in an acute care hospital for the purpose of completing a medically safe withdrawal from substances.

Inpatient detoxification is typically indicated when there is a risk of severe withdrawal symptoms or seizures, and/or co-occurring medical or mental health conditions that cannot be safely managed in a less intensive detoxification setting.

According to the DSM, the essential features of Substance Dependence Disorders include a maladaptive pattern of substance use as manifested by an increase in tolerance, an experience of withdrawal symptoms, unsuccessful attempts to control substance use, an increased amount of time spent on substance related activities, and the neglect of social and occupational activities within the same 12-month period.

The goals of inpatient detoxification are to:

Safely ameliorate and stabilize acute symptoms of withdrawal,

Stabilize the patient’s physical condition,

Identify the signs and symptoms of any co-occurring medical or psychiatric disorders and,

Facilitate the patient’s entry into substance use disorder treatment at the next, most appropriate level of care.

Inpatient Detoxification of Substance Use Disorders

Page 4 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

United Behavioral Health maintains that inpatient detoxification for substance dependence disorders should be consistent with its Level of Care Guidelines and

Inpatient detoxification is not for the purpose of providing custodial care, respite for the family, increasing social activity, or purely for antisocial (or runaway/truancy) behavior or legal problems, but for active 24-hour care that is:

Supervised and evaluated by a physician;

Provided under an individualized treatment or diagnostic plan;

Reasonably expected to improve the patient’s condition;

Unable to be provided in a less restrictive setting;

Focused on the presenting symptoms; and

Stabilizing the member’s condition to the extent that the member can be safely treated in a lower level of care.

In the event that the patient is remanded for treatment by the court, consider the member's acute symptoms and the precipitant for admission, the appropriateness of treatment, the terms of the member's benefit plan, the conditions of the court order, and applicable state law. In the event that UBH is court ordered to cover treatment, further legal examination and consultation with the court may occur particularly when there are changes to the patient’s clinical status that may indicate another level of care.

The requested inpatient detoxification services or procedures for the treatment of a substance dependence disorder must be reviewed against the language in the enrollee's benefit document. When the requested inpatient detoxification service or procedure is limited or excluded from the enrollee’s benefit document, or is otherwise defined differently, it is the terms of the enrollee's benefit document that prevails.

Benefits include the following services provided in an inpatient detoxification setting:

Diagnostic evaluations and assessment

Treatment planning

Referral services

Medication management

Individual, family, therapeutic group and provider-based case management services

Crisis intervention

The indications for coverage of inpatient detoxification for substance dependence disorders are summarized as follows:

Patients with Substance Dependence Disorders should be treated in a level of care that is most likely to prove safe and effective. Choice of inpatient

Inpatient Detoxification of Substance Use Disorders

Page 5 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

detoxification is driven by the type of substance used and the type and severity of withdrawal symptoms. Consider all of the following:

The patient is exhibiting signs and symptoms of severe withdrawal as a result of alcohol and/or drug use, requiring hourly monitoring and 24- hour medical management.

The patient’s Clinical Institute Withdrawal Assessment Scale (CIWA) score is at least 10.

The patient requires hourly monitoring due to the administration of intravenous medication or infusions, high levels of agitation or confusion, or extreme vital signs due to withdrawal.

The patient is experiencing or is likely to experience seizures, delirium tremens, or severe persistent hallucinations due to withdrawal.

The patient is experiencing severe opiate withdrawal that cannot be stabilized or managed at a less intensive level of care.

Intoxication and/or withdrawal due to stimulant use requiring psychiatric or medical management due to symptoms of psychosis, impulsivity or suicidality.

There has been recent head trauma or loss of consciousness with persistent neurological or mental status changes that requires hourly observation.

The patient has a biomedical and/or psychiatric disorder that will likely complicate detoxification at a less intensive level of care.

Best practices for the treatment of Substance Use Disorders in an inpatient detoxification setting:

Comprehensive Assessment

A physician is to complete an in-person comprehensive assessment within 3 hours of admission.

Indicated screening tools and structured interviews should be completed and may include:

o The Clinical Institute Withdrawal Assessment (CIWA-Ar), or

The Alcohol Use Disorders Identification Test (AUDIT), or

COWLS Reference

The Drug Abuse Screening Test (DAST), or

The Addiction Severity Index (ASI), or

The Structured Clinical Interview (SCID), or

The Stages of Readiness and Treatment Eagerness Scale (SOCRATES), or

Inpatient Detoxification of Substance Use Disorders

Page 6 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

The Drug and Alcohol Problem Screening for adolescents (DAP), or

The Teen Addiction Severity Index (T-ASI) for adolescents, or

The Adolescents Diagnostic Interview (ADI)

An assessment of mental status, imminent risk of harm to self or others, withdrawal symptoms or toxic effects from substances used is to be completed by a physician within 3 hours of admission.

A comprehensive addiction-focused history in addition to a physical examination is to be performed by a physician within 24 hours of admission and should include:

o

A detailed history of the patient’s past and present substance use:

This should include the types of substances used and whether multiple substances have been used in combination; and

The quantity, frequency, duration, route of administration and circumstances of substance use should all be gathered.

o

Evaluation of the effects of substance use on the patient’s cognitive, psychological, behavioral, social, occupational and physical functioning should be completed;

o

A detailed history of previous treatments and outcomes to include previous attempts to stop using, outcomes, duration of attempts and relapse reasons should be completed.

o

A family and social history;

o

Consider the use of evidenced based screening tools;

o

Toxicology and laboratory testing as needed;

Blood, urine and breath screening for substances and laboratory tests for abnormalities that may accompany acute or chronic substance use should be taken. These tests may also be used during treatment to monitor potential for relapse. Breath tests may also be useful in assessing alcohol use.

Screening for infectious disease such as HIV and Hepatitis C may also be necessary.

Consider whether pregnancy testing or diagnostic testing for additional medical conditions is required;

Inpatient Detoxification of Substance Use Disorders

Page 7 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

o

Determine prior psychiatric or medical treatments and currently prescribed medications.

o

Contact family and significant others for collateral information;

o

Continuously assess patient’s motivation and readiness to change to include:

Awareness of the existence of a problem, desire to stop, motivations to use and barriers to treatment.

Treatment Plan

The choice of treatment should be informed by factors such as the patient’s age and developmental level.

Within the first 24 hours of admission the provider and, whenever possible, the patient document clear, reasonable and objective treatment and recovery goals that stem from the patient’s diagnosis, and are supported by specific treatment strategies which address the patient’s symptoms, and take into account the patient’s preferences and readiness for change. The treatment plan must include objectives, actions and timeframes to address ALL of the following:

o

Interventions for monitoring and managing vital signs, withdrawal symptoms, co-occurring medical conditions, and medication side effects.

o

Inventorying the patient’s strengths and other psychosocial resilience factors such as the patient’s support network.

o

A determination as to whether the patient has an advance directive, a recovery plan, and a plan for managing relapse.

o

How symptom reduction and rapid stabilization will be achieved.

o

How co-occurring mental health conditions, if any, will be managed.

o

How the patient’s ability to manage their condition will be improved such as by providing health education, and linking the patient with peer services and other community resources such as an age-appropriate organized sobriety support group if clinically indicated including a recommendation for obtaining an accountability partner such as a sponsor or re-connecting with an accountability partner if the patient already has one.

o

How risk issues related to the patient’s presenting condition, co- occurring mental health conditions, or co-occurring medical conditions will be managed including how the patient’s motivation will be maintained/enhanced, provision of close supervision of behavior, addressing medication effects or possible side effects, and collaborating with the patient to develop/revise the advance directive or relapse prevention plan.

Inpatient Detoxification of Substance Use Disorders

Page 8 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

o

Contacting the patient’s family and/or social support network, with the patient’s documented consent, within the first 48 hours of admission to regularly participate in the patient’s treatment and discharge planning when such participation is essential and clinically appropriate.

o

Contacting the patient’s outpatient provider, with the patient’s documented consent, within the first 48 hours of admission if the patient was in treatment prior to admission to obtain information about the patient’s presenting condition and its treatment.

o

The plan to coordinate treatment with agencies and programs such as the school or court system with which the patient has been involved when appropriate and with the patient’s documented consent.

o

Initially identifying the next appropriate level of care within 24 hours of admission including an anticipated date of discharge and actions to be taken to facilitate the patient’s transition.

o

The provider and, whenever possible, the patient collaborate to update the treatment plan at least every 2 days in response to changes in the patient’s condition, or provide compelling evidence that continued treatment in the current level of care is required to prevent acute deterioration or exacerbation of the patient’s current condition.

Psychosocial/Medical Interventions

A highly individualized biomedical, emotional, behavioral and addiction focused treatment plan with 24-hour nursing care and medical management should be implemented.

Interventions should target the concomitant medical, emotional and cognitive conditions in the context of addiction treatment.

Hourly or more frequent nurse monitoring and medical management is necessary.

Acutely intoxicated patients should be provided with decreased exposure to external stimuli, reassurance, reorientation, and reality testing that is safe and closely monitored.

Therapies may be initiated in anticipation that treatment will continue after discharge according to the patient's response to detoxification. Psychotherapy such as Cognitive Behavior Therapy (CBT), Motivational Enhancement Therapy (MET), and other behavior therapies appropriate for the patient’s stage of “readiness to change” as well as the patient’s understanding of his/her substance use disorder may be chosen.

Inpatient Detoxification of Substance Use Disorders

Page 9 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

Therapy to occur simultaneous with the detoxification process and according to the patient’s stage in readiness to change.

Treatment engagement with the use of motivational enhancement methods, health education, psychoeducation, and services to families and significant others should be aimed at promoting participation in future treatment.

For the patient that has a severe medical and/or psychiatric disorder, psychiatric interventions will compliment addiction treatment.

Pharmacotherapy/Detoxification Interventions

Detoxification pharmacotherapy includes Intoxication and withdrawal interventions.

When managing intoxication, consider the following:

o

The substances used, route of administration, the dose, the time since the last dose, and whether the level of intoxication is waxing or waning all needs to be ascertained. When multiple substances have been used, the effects of each substance should be considered.

o

The removal of substances from the body via gastric lavage or techniques that increase the excretion rate of substances or their active metabolites may be chosen.

o

Medications that antagonize the actions of the abused substances may be used to reverse their effect. Examples include the administration of naloxone to patients who have overdosed with heroin or other opioids or flumazenil to patients who have overdosed on benzodiazepines.

o

Intubation to decrease aspiration or medications to support blood pressure are approaches that can be used to stabilize the physical effects of an overdose.

When managing withdrawal, consider the following:

o

Physically dependent individuals who discontinue their substance use after heavy or prolonged use may need to be monitored for withdrawal syndromes.

o

Consider factors that may influence severity of withdrawal (type of substance used and rate of metabolism or co-occurring conditions).

o

Replace the abused drug with a drug in the same or similar class with a longer duration of action and taper the longer-acting drug.

Inpatient Detoxification of Substance Use Disorders

Page 10 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

o Treat with medications to ameliorate withdrawal symptoms such as clonidine for opioid withdrawal or benzodiazepines or anticonvulsants for alcohol withdrawal.

Specific attention should be given to the medication evaluation and management of patients with active psychiatric and/or medical symptoms.

o Medications to treat co-occurring medical and/or psychiatric conditions may be chosen with close monitoring of possible interactions during the detoxification process.

Drug interactions, non-adherence and overdose are clinically significant areas that require ongoing assessment when treating patients with co-occurring psychiatric and substance use disorders in an inpatient setting.

Discharge and Aftercare Planning

The provider and, whenever possible, the member collaborate to update the initial discharge plan so that an appropriate and final discharge plan is in place prior to discharge. Whenever possible, the treatment team should review the discharge plan with the provider at the next level of care prior to discharge. The final discharge plan should be provided to the Care Advocate at least 24 hours prior to the anticipated date of discharge.

The discharge plan must include ALL of the following:

o

The anticipated discharge date.

o

The level and modalities of post-discharge care including the following:

o

The next level of care, its location, and the name(s) of the provider(s) who will deliver treatment;

o

The rationale for the referral;

o

The date and time of the first appointment for treatment as well as the first follow-up psychiatric assessment;

o

The first appointment should be within 7 days of discharge;

o

The recommended modalities of care and the frequency of each modality;

o

The names, dosages and frequencies of each medication, and a schedule for appropriate lab tests if pharmacotherapy is a modality of post-discharge care;

o

Linkages with peer services and other community resources such as an age-appropriate sobriety group, accountability partner such as a sponsor, or other resource that will aid in the member’s recovery.

Inpatient Detoxification of Substance Use Disorders

Page 11 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

o

The plan to communicate all pertinent clinical information to the provider(s) responsible for post-discharge care, as well as to the member’s primary care provider as appropriate.

o

The plan to coordinate discharge with agencies and programs such as the school or court system with which the member has been involved when appropriate and with the member’s documented consent.

o

A prescription for a supply of medication sufficient to bridge the time between discharge and the scheduled follow-up psychiatric assessment.

o

Confirmation that the member understands and agrees with the discharge plan.

o

Confirmation that the member was provided with written instruction for what to do in the event that a crisis arises prior to the first post-discharge appointment.

In Some Situations United Behavioral Health May Offer:

Peer Review: United Behavioral Health will offer a peer review to the provider when services do not appear to conform with this guideline. The purpose of a peer review is to allow the provider the opportunity to share additional or new information about the case to assist the Peer Reviewer in making a determination including, when necessary, to clarify a diagnosis.

Second Opinion Evaluation: United Behavioral Health facilitates obtaining a second opinion evaluation when requested by an enrollee, provider, or when United Behavioral Health otherwise determines that a second opinion is necessary to make a determination, clarify a diagnosis or improve treatment planning and care for the enrollee.

Referral Assistance: United Behavioral Health provides assistance with accessing care when the provider and/or enrollee determine that there is not an appropriate match with the enrollee’s clinical needs and goals, or if additional providers should be involved in delivering treatment.

Inpatient Detoxification requires pre-service notification. Notification of a scheduled admission must occur at least five (5) business days before admission. Notification of an unscheduled admission (including Emergency admissions) should occur as soon as is reasonably possible. In the event that United Behavioral Health is not notified of an Inpatient Detoxification admission, benefits may be reduced. Check the member’s specific benefit plan document for the applicable penalty and provision for a grace period before applying a penalty for failure to notify UBH as required.

Covered Health Service(s) – UnitedHealthcare 2001

Those health services provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance abuse, or their symptoms. A Covered Health Service is a health care service or supply described in Section 1:

Inpatient Detoxification of Substance Use Disorders

Page 12 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

What's Covered--Benefits as a Covered Health Service, which is not excluded under Section 2: What's Not Covered--Exclusions.

Covered Health Service(s) – UnitedHealthcare 2007 and 2009

Those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following:

Provided for the purpose of preventing, diagnosing or treating a Sickness, Injury, mental illness, substance abuse, or their symptoms.

Consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines as described below.

Not provided for the convenience of the Covered Person, Physician, facility or any other person.

Described in this Certificate of Coverage under Section 1: Covered Health Services and in the Schedule of Benefits.

Not otherwise excluded in this Certificate of Coverage under Section 2:

Exclusions and Limitations.

In applying the above definition, "scientific evidence" and "prevailing medical standards" shall have the following meanings:

"Scientific evidence" means the results of controlled clinical trials or other studies published in peer-reviewed, medical literature generally recognized by the relevant medical specialty community.

"Prevailing medical standards and clinical guidelines" means nationally recognized professional standards of care including, but not limited to, national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines.

United Behavioral Health maintains clinical protocols that include the Level of Care Guidelines and Best Practice Guidelines which describe the scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations. These clinical protocols (as revised from time to time), are available to Covered Persons upon request, and to Physicians and other behavioral health care professionals on ubhonline.

COVERAGE LIMITATIONS AND EXCLUSIONS

Inconsistent or Inappropriate Services or Supplies – UnitedHealthcare 2001, 2007, 2009

Services or supplies for the diagnosis or treatment of substance use that, in the reasonable judgment of United Behavioral Health, are any of the following:

Not consistent with generally accepted standards of medical practice for the treatment of such conditions.

Inpatient Detoxification of Substance Use Disorders

Page 13 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

Not consistent with services backed by credible research soundly demonstrating that the services or supplies will have a measurable and beneficial health outcome, and are therefore considered experimental.

Not consistent with United Behavioral Health’s level of care guidelines or best practice guidelines as modified from time to time.

Not clinically appropriate for the patient’s substance use disorder or condition based on generally accepted standards of medical practice and benchmarks.

Additional Information: The lack of a specific exclusion of a service does not imply that the service is covered.

The following are examples of inconsistent or inappropriate services for the treatment of Substance Use Disorders (not an all inclusive list):

Services that deviate from the indications for coverage summarized in the previous section.

Confinement in an inpatient facility without appropriate management of acute symptoms.

Confinement in an inpatient facility for the sole purpose of awaiting placement in a long-term facility.

Confinement in an inpatient facility that does not provide adequate nursing care and monitoring, or physician coverage.

Not coordinating care when more than one practitioner is delivering treatment.

Not addressing co-occurring behavioral health or medical conditions including substance disorders in the treatment plan.

Services continue even though stabilization has been completed and rehabilitation can be provided in a less intensive setting.

Please refer to the enrollee’s benefit document for ASO plans with benefit language other than the generic benefit document language.

{INCLUDE FOR ASO ONLY:

For ASO plans with SPD language other than 2001 and 2007 Generic COC language,

Please refer to the enrollee’s plan specific SPD for coverage.

DEFINITIONS

Agonist

patient's body but do not provide the same result for the patient as the substance

Drugs that mimic the substance the patient is addicted to in the

Inpatient Detoxification of Substance Use Disorders

Page 14 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

they have been ingesting. Agonists are given in gradually decreasing doses and the patient does not experience uncomfortable withdrawal symptoms.

Antagonist A substance that tends to nullify the effect of another (e.g., a drug that binds to a receptor without eliciting a response).

CIWA Scale The Clinical Institute Withdrawal Assessment is an assessment tool used for monitoring withdrawal symptoms from alcohol. The assessment takes approximately 5 minutes to administer. The maximum score is 67and patients scoring less than 10 do not typically need additional medication for withdrawal.

Co-Occurring Conditions Formerly known as dual diagnosis or dual disorder, co-occurring disorders describe the presence of two or more disorders at the same time. For example, a person may suffer substance abuse as well as bipolar disorder.

Detoxification The metabolic process by which the toxic qualities of a poison or toxin are reduced by the body. Pertaining to addiction it is generally a medically supervised treatment for alcohol or drug addiction designed to purge the body of intoxicating or addictive substances. Such a program is used as a first step in overcoming physiological or psychological addiction.

Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) A manual produced by the American Psychiatric Association which provides the diagnostic criteria for mental health and substance-related disorders, and other problems that may be the focus of clinical attention. Unless otherwise noted, the current edition of the DSM applies.

Inpatient Detoxification Inpatient detoxification is comprised of services that are provided in an acute care hospital for the purpose of completing a medically safe withdrawal from substances. Inpatient detoxification is typically indicated when there is a risk of severe withdrawal symptoms or seizures, and/or co- occurring medical or mental health conditions that cannot be safely managed in a less intensive detoxification setting.

Substance Dependence A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three or more of the following occurring at any time within the same 12-month period. They include, an increase in tolerance and/or diminished effect of substance, symptoms of withdrawal, increases in amount of use, a desire and failure to control substance use, spending a great deal of time in substance related activities, important social, interpersonal and occupational activities are neglected and, a known physical or mental condition has worsened with the continued use of substances.

Withdrawal Consists of a predictable group of signs and symptoms resulting from abrupt removal of, or a rapid decrease in, the regular dosage of a psychoactive substance. The syndrome is often characterized by over activity of the physiological functions that were suppressed by the drug and/or depression of the functions that were stimulated by the drug.

Inpatient Detoxification of Substance Use Disorders

Page 15 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

Withdrawal Symptoms Withdrawal from opioids or alcohol can be severe and excruciating. Withdrawal generally begins between 4 to 72 hours after the last use (depending on the extent of use), The symptoms are both physical and emotional and include: dilated pupils, goose bumps, watery eyes, runny nose, yawning, loss of appetite, tremors, panic, chills, nausea, dry heaves, muscle cramps, insomnia, stomach cramps, diarrhea, vomiting, shaking, chills or profuse sweating, irritability, jitters, and increased sensitivity to pain.

REFERENCES

1. Generic UnitedHealthcare Certificate of Coverage, 2001

2. Generic UnitedHealthcare Certificate of Coverage, 2007

3. Generic UnitedHealthcare Certificate of Coverage, 2009

4. American Academy of Child and Adolescent Psychiatry, Practice Parameter for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders, 2007,

http://www.aacap.org/galleries/PracticeParameters/JAACAP%20Substance%

20use%202005.pdf

5. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Substance Use Disorders, 2006,

http://www.psychiatryonline.com/Practice%20Guideline/PDFsSUD2ePG_04-

28-06.pdf

6. American Psychiatric Association, Practice Guideline for the Treatment of Patients with Substance Use Disorders, Guideline Watch 2007,

http://www.psychiatryonline.com/pracGuide/PracticePDFs/SUDwatch041307.

pdf

7. American Society of Addiction Medicine, ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition, Revised,

2001

8. Clinical Practice Guideline, Management of Substance Use Disorders, VA/DoD Evidenced Based Practice, 2009,

http://www.healthquality.va.gov/sud/sud_full_601f.pdf

9. Custodial Care Coverage Determination Guideline, United Behavioral Health,

2010.

10. Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Improvement Protocols, Screening and Assessment Instruments, 2011. http://www.ncbi.nlm.nih.gov

CODING

The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are for reference purposes only. Listing of a service code in this guideline does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document.

Inpatient Detoxification of Substance Use Disorders

Page 16 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011

Limited to specific CPT and HCPCS codes?

H0008,H0009

X YES

NO

Alcohol and/or drug services; acute detoxification (hospital inpatient)

Alcohol and/or drug services; acute detoxification (hospital inpatient)

Limited to specific diagnosis codes?

x YES

NO

303.90

Alcohol Dependence

304.40

Amphetamine Dependence

304.20

Cocaine Dependence

304.00

Opioid Dependence

304.10

Sedative, Hypnotic or Anxiolytic Dependence

304.80

Polysubstance Dependence

Limited to place of service (POS)?

x YES

NO

Inpatient Hospital

Limited to specific provider type?

YES

x NO

Limited to specific revenue codes?

YES

x NO

HISTORY

Revision Date

Name

Revision Notes

12/5/2011

Loretta Urban

 

The enrollee's specific benefit documents supersede these guidelines and are used to make coverage determinations. These Coverage Determination Guidelines are believed to be current as of the date noted.

Inpatient Detoxification of Substance Use Disorders

Page 17 of 17

Coverage Determination Guideline Confidential and Proprietary, © United Behavioral Health 2011