Sunflower Health Plan Substance Use Disorders Treatment and Services (PDF) Form

This policy applies to all staff involved in the design, implementation, operations, and management of Behavioral Health utilization management services for Centene Advanced Behavioral Health (CABH) for the Medicaid, Medicare, and Marketplace lines of business. This clinical policy outlines the utilization management of authorization requests for substance use disorder treatment within the Centene Corporation. Policy/Criteria I. It is the policy of Centene Advanced Behavioral Health and health plans affiliated with Centene Corporation® to utilize the American Society of Addiction Medicine (ASAM) Criteria, Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition for substance use disorder treatment medical necessity determinations. The ASAM Criteria include both adult and adolescent criteria and incorporate both substance use disorders and co-occurring disorders within the criteria. Plans managed by CABH may require the use of other evidence-based guidelines, both instead of the ASAM Criteria or in addition to the ASAM Criteria. Examples of these guidelines include, but are not limited to, InterQual SUD Criteria located within the Centene Management System. may also be applied to determine the medical necessity of SUD treatment . Background Substance use disorders (SUD) are chronic, relapsing medical conditions that have genetic, environmental and exposure origins that involve neurobiological brain circuit changes which result in compulsive use of substances. These substances include illicit drugs or agents as well as legal agents and prescriptions and belong to a variety of classes. SUDs are often co-morbid with other psychiatric and general medical conditions and can be fatal. They are devastating to individuals, communities and society at large. The United States leads the world in opioid prescriptions, which is a risk factor for substance use disorder. Up to 30% of those prescribed opioids abuse their prescriptions and 12% of those develop a substance use disorder.26 Only 10% of individuals with SUD in the USA get treatment. Oftentimes, when individuals seek treatment, they encounter a system that is fraught with bias/stigma, fragmented and uncoordinated. However, when they do get appropriate treatment, individuals recover from SUD at similar rates as from other chronic medical conditions. CABH policy on substance use treatment is based on the best current evidence for treatment that supports recovery. The basic six principles of this care, which aligns with relevant guiding principles of the ASAM Criteria, are the following: 1. Comprehensive: Incorporates all current evidence-based treatments, including medication assisted treatment. Treatment should address medical, mental health and social determinants. Page 1 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services 2. Patient-Centered: Individualized, flexible treatment approach. 3. Does not require a “fail first”: current standards recommend all indicated treatments be implemented at the time the individual seeks treatment, without requiring other types/levels of care be “failed first.” 4. Parity: SUD treatment should be covered equally with other medical treatments as required under parity laws. 5. Least restrictive: Consistent with other medical treatment, less restrictive medically necessary treatment options should be considered when these less restrictive options are available to the member and when these options are considered both equally safe and equally effective compared to higher levels of care. 6. Motivation and Member Engagement: Client motivation and engagement are at the heart of any successful treatment. Motivational enhancement techniques should be incorporated at every stage of client contact. THE ROLE OF MEDICATION-ASSISTED TREATMENT (MAT) IN SUBSTANCE USE TREATMENT. There is a strong evidence base for the efficacy of medication in the treatment of substance use disorders when combined with psychotherapy and behavioral strategies. This is called medication-assisted treatment (MAT). MAT is considered the standard of care for opioid and other substance use disorders. This type of treatment falls into two broad categories: A. Medications used to support abstinence and recovery maintenance. B. Medications used to manage withdrawal or intoxication. Categories of medication used to support abstinence and recovery: a. Antagonist medications e.g., naltrexone/Vivitrol® b. Agonist medications e.g., methadone, nicotine replacement therapies. c. Partial agonist medications e.g., Buprenorphine, Varenicline® d. Novel mechanisms of action e.g., acamprosate/Campral R e. Aversive agents such as Disulfiram (Antabuse®) f. Novel treatments/alternative mechanisms of action/off-label use: e.g. (Gabapentin & Baclofen for alcohol use disorders), Buproprion (for smoking cessation). Medications used primarily to treat overdose and withdrawal states: Medication can be used to treat withdrawal symptoms and facilitate a safer medical withdrawal when warranted. Others can be used to treat overdose states. When using drugs to mediate withdrawal, use of rating scales are strongly recommended. Examples are the CIWA-Ar and COWS. These scales enable the provider to evaluate the severity of withdrawal and to determine the best treatment course. Drugs used to treat intoxication or overdose states include i. Naloxone: used to reverse opioid overdose. Several different formulations exist, from intranasal to intramuscular; this may be lifesaving in overdose. Page 2 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services ii. Flumazenil: used to reverse benzodiazepine overdose. Opioid Withdrawal Protocols: a. Using opioid substitution: - Buprenorphine - Methadone b. Using clonidine and other comfort medications. Lofexidine has a similar mechanism of action as clonidine and is FDA approved for treating opioid withdrawal. However, its higher cost may be a consideration in its use. Alcohol Withdrawal Protocols: a. Using benzodiazepine substitution b. Using phenobarbital substitution c. Using anticonvulsants meds (gabapentin, carbamazepine) d. Always administer B1 (thiamine) 250-500 mg TID depending on presentation; parenteral route is preferred and can be transitioned to once daily dosing oral treatment as individual recovers Sedative-Hypnotics Withdrawal Protocols: a. Using phenobarbital substitution b. Using clonazepam substitution c. Using other benzodiazepine substitution d. B vitamins, especially B12, folate, thiamine and PRN comfort meds addressing peripheral symptoms of withdrawal should be used as needed. Adequate Magnesium levels should be assured. Medications used to maintain abstinence and to support recovery: There now exists a strong evidence base for the use of medication to maintain abstinence and support recovery during SUD Treatment. Such medications, when combined with counseling and behavioral therapies, increase retention rates, and are associated with better health and social outcomes for some patients. They should be offered to all individuals seeking treatment for those substance use disorders where there is clinical evidence of their efficacy unless there is a medical contraindication. Best practices recommended by National Institute of Drug Abuse (NIDA) and American Society of Addiction Medicine (ASAM) regarding Medication Assisted Treatment implementation include: • Medication to decrease urges or cravings for:  Alcohol Page 3 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services o Acamprosate: Administer after a minimum of five days abstinence from alcohol. Start at 333 mg TID for 3 days and then increase to 666 mg TID; this should be offered as an integral part of the SUD treatment recommendation to all patients with alcohol use disorder and reporting cravings >3/10 as soon as they have been managed for withdrawal and throughout their SUD treatment stages as long as they are experiencing benefit from the medication as noted by lowered levels of craving, reduced rumination, and abstinence maintenance. • Medications to decrease the reinforcing effects of:  Alcohol o Naltrexone PO: usual daily dose is 50 mg; this should be offered as an integral part of the treating alcohol use disorder. Alternative dosing is possible. Liver enzymes should be monitored during treatment. o Naltrexone depot IM (Vivitrol): 380 mg IM every 4 weeks; this should be offered as part of the integral treatment plan recommendations to the same patients as noted above after they have shown good tolerance to Naltrexone PO and prefer this route or have continued to be high risk for relapse.  Opioids o Naltrexone: patients must be opioid free 7-14 days; this should be reviewed and offered as an integral part of the SUD treatment recommendation to all opioid use disorder patients as ONE of the three FDA approved medications to reduce reported ongoing cravings. While oral naltrexone is available to patients with OUD, injectable naltrexone is recommended given the risk of reduced tolerance in patients who have stopped using opioids for a period of time, therefore increasing the risk of overdose should that person not continue to take the oral medication. o Naltrexone depot IM (Vivitrol®): 380 mg IM every 4 weeks; this formulation is recommended over the oral form for opioid use disorder. This should be offered as an integral part of the treatment planning to patients who choose to take an antagonist to reduce cravings and reduce the risk of relapse. The patients can be started on this after they have shown tolerance to a naloxone challenge or Naltrexone PO (even after one dose). • Agonist or mixed agonist/antagonist maintenance therapies for:  Opioids: This should be offered as part of the treatment planning options to opioid use disorder patients. Page 4 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services  Methadone: 40-60 mg/day or less of methadone is usually sufficient to block opioid withdrawal symptoms. Higher doses (80-120 mg/ day) have been shown to curb dramatically additional use of opioids.  Buprenorphine-only formulations: in some practices used for pregnant patients or in those with an adverse reaction to naloxone.  Buprenorphine/naloxone combination (ranging between mg/0.5 mg – 32 mg/8 mg per day, sublingual once daily or in divided doses). Typical daily doses rarely exceed 16/4 mg in ambulatory settings. The dosing is based on individual histories and needs. • Abstinence-promoting and relapse prevention therapies for: Alcohol:  Disulfiram: usual dose 250 mg/day, rarely: 125 mg/day – 500 mg/day (typically aversive if used with alcohol). This medication can be helpful for patients who continue to be unable to avoid consuming alcohol despite use of other medications as listed AND have an individual willing to ‘witness dose’ the patient. Studies do not bear out that disulfiram has long term benefit for patients with alcohol use disorder unless under this condition. Liver function tests and Complete Blood Counts should be checked periodically.  Psychosocial evaluation within 48 hours  Individual or group therapy at least 2x/day  Recovery or education group daily  Family therapy at least 1x/week  Nursing staff observation 24 hours/day  Educational assessment for patients aged 13-17  Self-help group recommended Additional MAT Considerations 1. Duration of MAT Use: In accordance with the principles of person-centered care, it is no longer recommended to place arbitrary limits on duration of MAT. Similar with treatment of other chronic medical conditions such as diabetes, asthma, hypertension and cancer, many individuals will require long term or lifetime treatment with MAT. Treatment planning is determined between the provider and the patient and in conjunction with other multidisciplinary team members. 2. Long-Acting Drug Formulations: There now exist several long – acting formulations of drugs used for MAT. These include i. ii. iii. Long-acting injectable naltrexone (Vivitrol®) Long-acting injectable buprenorphine (Sublocade®). Long-acting implantable buprenorphine (Propbuphine®) These formulations may be especially helpful in individuals who struggle with adherence. They may also be useful in individuals who have stabilized and require maintenance treatment. Page 5 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services 3. MAT in Special Populations: a. Pregnancy b. Adolescents c. Reentry populations d. Chronic infections: HIV/Hepatitis C positive, tuberculosis. Special considerations apply in the treatment of those who are pregnant, adolescent individuals, those with chronic infections and of those who are re-entrants from corrections. These populations are particularly vulnerable and may especially benefit from MAT. For others, dose or medication adjustments may be needed. For example, in adolescents and pregnant women. Women who become pregnant while on naltrexone or Vivitrol® may need to be switched to an agonist such as methadone or partial agonist such as buprenorphine, though retrospective studies are now beginning to support continued antagonist treatment in pregnancy. As of this date, it is not standard of care. When treating adolescents, age considerations will need to be reviewed based on medication age approvals while maintaining a focus on unique individual treatment needs. 4. “Medication First” and Other Emerging National Models: In response to the Opioid epidemic, states are experimenting with different models of leveraging MAT in addiction treatment. A prominent example is the “Medication first” model in Missouri State.1 Medication first is conceptually similar to the Housing First model. Its core principles are as follows a. People with OUD receive pharmacotherapy treatment as quickly as possible, prior to lengthy assessments or treatment planning sessions; b. Maintenance pharmacotherapy is delivered without arbitrary tapering or time limits; c. Individualized psychosocial services are continually offered but not required as a condition of pharmacotherapy; d. Pharmacotherapy is discontinued only if it is worsening the person’s condition. While this model is in its early stages of implementation, there is a solid basis for it. Efforts to accommodate similarly innovative models should be made on a local and state level. LEVEL OF CARE GUIDELINES. The ASAM Criteria Level of Care Guidelines are used upon admission to assess the need for continued care, and discharge from each level of care. In addition to ASAM, other evidence- based guidelines such as, but not limited to, InterQual SUD Criteria located within the Centene Management System may also be applied to determine the medical necessity of SUD treatment. Since SUDs are chronic, relapsing disorders with a highly variable course, they often require intensive, sustained, coordinated and comprehensive treatment. This is similar to diabetes or cancer treatment. Current standards advocate the incorporation of MAT, counseling, 1 https://missouriopioidstr.org/updates/2018/9/13/medication-first-model-1-pager Page 6 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services psychosocial treatments, relapse prevention strategies, and concurrent treatment of co-occurring mental health and medical conditions. ASAM CRITERIA LEVEL OF CARE GUIDELINES. When paired with MAT, counseling, psychosocial treatments, and safe housing including attention to social determinants, ambulatory treatment at ASAM levels 1 through 2.5 can be as, or more effective than more intensive treatment at higher ASAM levels. Centene uses ASAM criteria, Level of Care Guidelines and other evidence-based guidelines to outline objective and evidence-based criteria to standardize coverage determinations and utilization management (UM) practices for Centene-affiliated health plans whose BH UM function has been delegated to Centene Advanced Behavioral Health (CABH). The Substance use Disorders (SUD) Criteria are designed for patients 13 years of age and older presenting with a predominant symptom of a SUD. Before using this guideline, please check the member’s specific benefit plan requirements and any federal or state mandated requirements, if applicable. MEDICALLY MANAGED INTENSIVE INPATIENT SERVICES – Level 4 ASAM Introduction This level of care occurs in an acute care or psychiatric inpatient hospital unit for patients with acute biomedical, emotional, behavioral, and cognitive problems so severe that they require primary medical and nursing care. Patients may require acute medical treatment to address acute intoxication and/or withdrawal potential 24 hours/day for medical issues related to substance use; complex SUD with severe psychiatric symptoms; or in acute danger of medical complications related to substance use and require a 24-hour medical management to ensure safety. Evaluation and Treatment Service delivery will vary based on legislative and organizational policy as well as geographic variances but, at a minimum, should include: • Care coordination with other care providers and social services • Toxicology screen within 4 hours • Nursing assessment within 8 hours of admission • Substance use evaluation within 8 hours • Discharge plan initiated within 24 hours • Medical history or physical exam initiated within 24 hours • Psychiatric evaluation, initial within 24 hours prior to or within 24 hours after admission – subsequently at least 1x/day • Daily physician evaluations • Medication management daily • Medication reconciliation within 24 hours • Psychosocial evaluation within 48 hours • Multidisciplinary treatment plan within 48 hours Page 7 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services Individual or group or family therapy daily • • Nursing staff observation 24 hours/day • Educational assessment for patients aged 13-17 • Toxicology screen as clinically indicated, education group, or self-help as needed MEDICALLY MANAGED INTENSIVE INPATIENT WITHDRAWAL MANAGEMENT– Level 4-WM ASAM Patients that require monitoring or intervention more frequently than hourly; or Need stabilization while pregnant, until the patient can be safely treated in a Introduction Level 4-WM provides medical support and comfort care needed for: • • less intensive level of care. Inpatient withdrawal criteria are used for a patient who has been or is expected to be admitted to an inpatient unit and requires medically managed withdrawal services. Patients may require acute medical treatment to address acute intoxication and/or withdrawal potential 24 hours/day for medical issues related to substance use; complex SUD with severe psychiatric symptoms; or in acute danger of medical complications related to substance use and require a 24-hour medical management to ensure safety. Maintenance medications may be considered at this level of care. Medications used primarily to treat intoxication and withdrawal states will require consistent use of withdrawal measuring scales (CIWA-R, COWS) to evaluate severity of withdrawal signs and symptoms and determine appropriate taper of substitution medications: Opioid Withdrawal Protocols: a. Using opioid substitution: - Buprenorphine - Methadone - Other opioids b. Using clonidine Alcohol Withdrawal Protocols: a. Using benzodiazepine substitution b. Using phenobarbital substitution c. Using anticonvulsants meds (gabapentin, carbamazepine) Sedative-Hypnotics Withdrawal Protocols: a. Using phenobarbital substitution b. Using clonazepam substitution c. Using other benzodiazepine substitution. d. Always administer B1 (thiamine) 250-500 mg TID depending on presentation; parenteral route is preferred and can be transitioned to once daily dosing oral treatment as individual recovers. Evaluation and Treatment • B vitamins, especially B12, folate, thiamine and PRN comfort meds addressing peripheral symptoms of withdrawal should be used as needed. Page 8 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services Service delivery will vary based on legislative and organizational policy as well as geographic variances but, at a minimum, should include: • Care coordination with other care providers and social services • Toxicology screen within 4 hours • Nursing assessment within 8 hours of admission • Substance use evaluation within 8 hours • Discharge plan initiated within 24 hours • Medical history or physical exam initiated within 24 hours • Psychiatric evaluation, initial within 24 hours prior to or within 24 hours after admission – subsequently at least 1x/day • Medication reconciliation within 24 hours • Psychosocial evaluation within 48 hours • Multidisciplinary treatment plan within 48 hours • Daily Physician evaluation • • Nursing staff observation 24 hours/day • Educational assessment for patients aged 13-17 • Toxicology screen as clinically indicated, education group, or mutual help as Individual or group or family therapy daily needed MEDICALLY MONITORED INTENSIVE INPATIENT PROGRAMS (ADULTS); HIGH INTENSITY (ADOLESCENTS) Level 3.7 ASAM Introduction These services are differentiated from Level 4.0 in that the population served does not have conditions severe enough to warrant medically managed inpatient services or acute care in a general hospital where daily treatment decisions are managed by a physician. Level 3.7 is appropriate for adults and adolescents with co-occurring psychiatric disorders or symptoms that hinder their ability to successfully engage in SUD treatment in other settings. Services in this program are meant to orient or re- orient patients to daily life structures outside of substance use and requires 24-hour nursing/medical monitoring under the direction of a physician as part of a psychotherapeutic program. The main focus is to safely treat patients at high risk for withdrawal from substances and support patients to acknowledge, recognize and understand their SUD in order to safely transfer to a less intensive level of care. Observation Observation is a level of care that is not described as a discreet level of care in the ASAM criteria, however, the Criteria does recognize that some inpatient providers offer this service. • Providers may request authorization for psychiatric observation when patients have a comorbid psychiatric illness and a substance use disorder. • The psychiatric observation is typically for up to 23 hours though may be up to 48 hours in rare situations. Page 9 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services • This level of care is used for acute treatment of specific emergent psychiatric presentations that can be quickly assessed, stabilized and discharged to a less intensive level of care, or to determine the need for a more intensive level of care. • The psychiatric observation is not the same as a medical observation in that the medical observation is used in general medical settings without specialized psychiatric treatment resources. Evaluation and Treatment Service delivery will vary based on legislative and organizational policy as well as geographic variances but, at a minimum, should include: • Blood and urine laboratory screening within 6 hours • Medical history and physical examination within 6 hours • Initial psychiatric evaluation within 6 hours and subsequently daily by physician, nurse practitioner or psychologist as legally authorized by the state. • Nursing assessment within 4 hours and nurse staff observation 24 hours/day • Multidisciplinary treatment plan within 12 hours • Psychosocial and substance evaluation within 12 hours • If deemed necessary, individual, or family therapy daily • Care coordination with other health care or social service providers CLINICALLY MANAGED HIGH-INTENSITY RESIDENTIAL PROGRAMS (ADULT)/CLINICALLY MANAGED MEDIUM-INTENSITY RESIDENTIAL PROGRAMS (ADOLESCENT CRITERIA) – Level 3.5 ASAM Introduction • The RTC criteria are used for a patient who has been or is expected to be admitted to a SUD RTC. • This level of care is also referred to as clinically managed high or medium (for Adolescents) intensity residential services and considered a Level 3.5 ASAM. • Clinical Services are provided 24 hours/day, 7 days/week in a facility licensed for residential SUD treatment. Evaluation and Treatment Service delivery will vary based on legislative and organizational policy as well as geographic variances but, at a minimum, should include: • Structured therapeutic program at least 4 hours/day • Preliminary discharge plan initiated within 24 hours • Medication reconciliation initiated within 24 hours • Psychosocial and substance use evaluation within 48 hours • Medication supervision or administration daily • The intensity of nursing care and observation is sufficient to meet the patient’s needs. Page 10 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services • Biomedical enhanced services are delivered by appropriately credentialed medical staff, who are available to assess and treat co-occurring biomedical disorders. CLINICALLY MANAGED POPULATION-SPECIFIC HIGH-INTENSITY RESIDENTIAL PROGRAMS (SPECIFIED FOR ADULTS ONLY) – Level 3.3 ASAM Introduction This degree of residential treatment is specifically designed for specific adult populations with significant cognitive impairments resulting from substance use or other co-occurring disorders. • High-Intensity Residential Programs are appropriate when an adult's temporary or permanent cognitive limitations make it unlikely for them to benefit from other residential levels of care that offer group therapy and other cognitive-based relapse prevention strategies. • Cognitive impairments may be seen in individuals who suffer from an organic brain syndrome as a result of substance use, who suffer from chronic brain syndrome, who have experienced a traumatic brain injury, who have developmental disabilities, or are older adults with age and substance-related cognitive limitations. Individuals with temporary limitations receive slower paced, repetitive treatment until the impairment subsides and the patient is able to progress onto another level of care appropriate for their SUD treatment needs. • • Settings include structured, therapeutic rehabilitation facilities and traumatic brain injury programs located within a community setting, or in specialty units located within licensed healthcare facilities where high-intensity clinical services are provided in a manner that meets the functional limitations of patients. Such programs have direct affiliation with more or less intensive levels of care as well as supportive services related to employment, literacy training and adult education. • Physicians, physician extenders, and appropriate credentialed mental health professionals may lead treatment. • On-site 24-hour allied health professional staff supervise the residential component with access to clinicians competent in SUD treatment. • Clinical staff knowledgeable about biological and psychosocial dimensions of SUD and psychiatric conditions who have specialized training in behavior management support care. • Patients have access to additional medical, laboratory, toxicology, psychiatric and psychological services through consultations and referrals. • Specialized services are provided at a slower pace and in a repetitive manner to overcome comprehension and coping challenges. • This level of care is appropriate until the cognitive impairment subsides, enabling the patient to engage in motivational relapse prevention strategies delivered in other levels of care. • Level 3.3 clinically managed population-specific high-intensity residential services may be provided in a deliberately repetitive fashion to address the special needs of individuals for whom a Level 3.3 program is considered medically necessary. • Daily clinical services designed to improve the patient’s ability to structure and organize the tasks of daily living and recovery, to stabilize and maintain the stability of the Page 11 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services individual’s substance use disorder symptoms, and to help them develop and apply recovery skills are provided. • The skilled treatment services include a range of cognitive, behavioral and other therapies administered on an individual and group basis; medication management and medication education; counseling and clinical monitoring; educational groups; occupational and recreational therapies; art, music or movement therapies; physical therapy; clinical and didactic motivational interventions; and related services directed exclusively toward the benefit of the Medicaid-eligible individual. CLINICALLY MANAGED LOW-INTENSITY RESIDENTIAL PROGRAMS– Level 3.1 ASAM Introduction The criteria are used for patients that have been or are expected to be admitted to a structured recovery residence environment, staffed 24 hours a day, which provides sufficient stability to prevent or minimize relapse or continued use. Services are provided in a 24-hour environment, such as a group home. • Both clinic-based services and community-based recovery services are provided. Clinically, Level 3.1 requires at least 5 hours of low-intensity treatment services per week, including medication management, recovery skills, relapse prevention, and other similar services. In Level 3.1, the 5 or more hours of clinical services may be provided onsite or in collaboration with an outpatient services agency. • • Clinically managed low-intensity residential services are designed to improve the patient’s ability to structure and organize the tasks of daily living, stabilize and maintain the stability of the individual’s substance use disorder symptoms, and to help them develop and apply recovery skills. Evaluation and Treatment Patients receive: Individual, group, or family therapy, or some combination thereof • • Medication management. • Psychoeducation to develop recovery. • Relapse prevention, and • Emotional coping techniques. Treatment should promote personal responsibility and reintegrate the patient to work, school, and family environments. At a minimum, this level of care provides telephone and in-person physician and emergency services 24-hours daily, offers direct affiliations with other levels of care, and is able to arrange necessary lab or pharmacotherapy procedures Skilled treatment services include: Individual, group and family therapy. • • Medication management and medication education. • Mental health evaluation and treatment. • Motivational enhancement and engagement strategies. • Recovery support services. • Counseling and clinical monitoring. Page 12 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services • MAT; and • Intensive case management, medication management and/or psychotherapy for individuals with cooccurring mental illness. PARTIAL HOSPITAL PROGRAMS (PHP) – Level 2.5 ASAM Introduction PHPs are appropriate for patients who are living with unstable medical and psychiatric conditions. PHP services are able to provide 20 hours or more of clinically intensive programming each week to support patients who need daily monitoring and management in a structured outpatient setting that offer direct access to psychiatric, medical, and laboratory services. The programs may be free-standing or located within a larger health care system. PHP services are delivered by an interdisciplinary team to identify mental health disorders and potential issues related to prescribed psychotropic medications treatment in populations with SUD. PHP services include: Intensive outpatient services including individual and group counseling • • Educational groups • Occupational and recreational therapy • Psychotherapy • MAT • Motivational interviewing, enhancement and engagement strategies • Family therapy • Other skilled treatment services INTENSIVE OUTPATIENT PROGRAMS (IOP) – Level 2.1 ASAM Introduction IOPs are primarily delivered by substance use disorder outpatient specialty providers but may be delivered in any appropriate setting that meets state licensure or certification requirements. IOPs provide 9–19 hours of weekly structured programming for adults, or 6–19 hours of weekly structured programming for adolescents. Programs may occur during the day or evening, on the weekend, or after school for adolescents. Interdisciplinary teams of appropriately credentialed addiction treatment professionals including counselors, psychologists, social workers, addiction-credentialed physicians, and program staff, many of whom have cross-training to aid in interpreting mental disorders and deliver IOP services. At a minimum, this level of care provides a support system including medical, psychological, psychiatric, laboratory, and toxicology services within 24 hours by telephone or within 72 hours in person. Emergency services are available at all times, and the program should have direct affiliation with more or less intensive care levels and supportive housing. IOP services include: • Intensive outpatient services including individual and group counseling • Educational groups • Occupational and recreational therapy Page 13 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services • Psychotherapy • MAT • Motivational interviewing, enhancement and engagement strategies • Family therapy • Other skilled treatment services OUTPATIENT SERVICES (OP) – Level 1 ASAM Introduction OP services are appropriate as an initial level of care for patients with less severe disorders; for those who are in early stages of change, as a “step down” from more intensive services; or for those who are stable and for whom ongoing monitoring or disease management is appropriate. Individual or group or family therapy or medication management occurs less than 2 hours/day twice per week in an ambulatory care setting such as a clinic or office. Depending on organizational policy, services may also be provided in other settings such as school, home or via telemedicine. OP is designed to help patients achieve changes in alcohol and/or drug use and addictive behaviors and often address issues that have the potential to undermine the patient’s ability to cope with life tasks without the addictive use of alcohol, other drugs, or both. OP services may offer several therapies and service components including: Individual and group counseling • • Motivational enhancement • Family therapy • Educational groups • Occupational and recreational therapy • Psychotherapy • MAT, or; • Other skilled treatment services. OPIOID TREATMENT PROGRAMS (OTPS) Opioid treatment programs (OTPs) provide medication-assisted treatment (MAT) for persons diagnosed with opioid use disorder using any of three FDA-approved medications: methadone, buprenorphine, and naltrexone. OTPs dispense medication and are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT). The duration of treatment, type of medication, and medication dosage should be based on the needs of each person served, and objective withdrawal criteria should be used. Services are directed at improving quality of life and functioning by reducing or eliminating the use of illicit substances (to reduce criminal activity and/or the spread of infectious disease) and fostering vocational skills, family relationships, and community involvement. An OTP must be accredited by a CSAT-approved accrediting body like CARF®. CARF® accredits the majority of OTPs in the United States. Page 14 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services PEER RECOVERY SUPPORT SERVICES Introduction Peer Recovery Support Services and Non-Peer Recovery Support Services are non-clinical services delivered by a Peer Recovery Coach/Certified Recovery Support Worker (CRSW) to help patients and families identify and work toward strategies and goals for supporting, stabilizing and sustaining recovery. A CRSW is required to complete a minimum of the following: • Thirty (30) hours of approved recovery coach training; • Sixteen (16) hours of approved ethics training; • Six (6) hours of approved suicide prevention training; and • Three (3) hours of approved co-occurring mental health and substance use disorders training. CRSWs must be supervised by a Master Licensed Alcohol and Drug Counselor (MLADC); a Licensed Alcohol and Drug Counselor (LADC) that is permitted to independently practice; a LADC enrolled under a SUD Outpatient or SUD Comprehensive Medicaid provider type; a LADC who is also a Licensed Clinical Supervisor (LCS); or a licensed mental health provider who has completed the training described above plus an additional six (6) hours of approved training in the supervision of individuals delivering peer recovery support services. With the exception of peer and non-peer recovery services and continuous recovery monitoring, all services must be consistent with the “Addiction Counseling Competencies, TAP 21”. SUD Peer Recovery Services-General Requirements • Group services may only be provided when 2 or more individuals are present. • Treatment groups are limited to 12 individuals with one counselor present or 16 individuals when that counselor is joined by a CRSW or a second counselor. • Recovery support groups are limited to 8 individuals with one Peer Recovery Coach/CRSW present or 12 individuals when that Peer Recovery Coach/CRSW is joined by a second Peer Recovery Coach/CRSW. • All services must be delivered in accordance with the ASAM Criteria. This includes the use of ASAM criteria in admission, continuing care, transfer, and discharge criteria as well as ensuring that services are consistent with the guidelines provided for each level of care. • All services must be evidence based, as demonstrated by meeting one of the following criteria:  The service is listed on the SAMHSA Evidence-Based Practices Resource Center site;  The services have been published in a peer-reviewed journal and found to have positive effects; or  The provider can otherwise document the services’ effectiveness based on the following: 1. The service is based on a theoretical perspective that has validated research; or Page 15 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services 2. The service is supported by a documented body of knowledge generated from similar or related services that indicate effectiveness. Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2019, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT® Codes 80305 80306 80307 90791 90792 90832 through 90840 90845 through 90853 99201 through 99255 99281 through 99285 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; capable of being read by direct optical observation only (e.g., utilizing immunoassay [e.g., dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; read by instrument assisted direct optical observation (e.g., utilizing immunoassay [e.g., dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (e.g., utilizing immunoassay [e.g., EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (e.g., DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service Psychiatric diagnostic evaluation Psychiatric diagnostic evaluation with medical services Psychotherapy Other psychotherapy Evaluation and management services Emergency Department Services Page 16 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services CPT® Codes 99341 through 99350 99492 99493 99494 99408 99409 Home services Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: outreach to and engagement in treatment of a patient directed by the treating physician or other qualified health care professional; initial assessment of the patient, including administration of validated rating scales, with the development of an individualized treatment plan; review by the psychiatric consultant with modifications of the plan if recommended; entering patient in a registry and tracking patient follow-up and progress using the registry, with appropriate documentation, and participation in weekly caseload consultation with the psychiatric consultant; and provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies. Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional, with the following required elements: tracking patient follow-up and progress using the registry, with appropriate documentation; participation in weekly caseload consultation with the psychiatric consultant; ongoing collaboration with and coordination of the patient's mental health care with the treating physician or other qualified health care professional and any other treating mental health providers; additional review of progress and recommendations for changes in treatment, as indicated, including medications, based on recommendations provided by the psychiatric consultant; provision of brief interventions using evidence-based techniques such as behavioral activation, motivational interviewing, and other focused treatment strategies; monitoring of patient outcomes using validated rating scales; and relapse prevention planning with patients as they achieve remission of symptoms and/or other treatment goals and are prepared for discharge from active treatment. Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional (List separately in addition to code for primary procedure) Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes Page 17 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services HCPCS Codes A15.0 through A19.9 B17.10 through B17.11 B18.2 B19.20 through B19.21 B20 G0396 G0397 G0480 G0481 G0659 Tuberculosis Acute hepatitis C Chronic viral hepatitis C Unspecified viral hepatitis C without hepatic coma Unspecified viral hepatitis C with hepatic coma Human immunodeficiency virus [HIV] disease Alcohol and/or substance (other than tobacco) abuse misuse structured assessment (e.g., AUDIT, DAST), and brief intervention 15 to 30 minutes Alcohol and/or substance (other than tobacco) abuse misuse structured assessment (e.g., AUDIT, DAST), and intervention, greater than 30 minutes Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including but not limited to, GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem), excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic Page 18 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services HCPCS Codes H0001 H0002 H0003 H0004 H0005 H0006 H0007 H0008 H0009 H0010 H0011 H0012 H0013 H0014 H0015 H0016 H0017 H0018 H0019 H0020 H0021 methods (e.g., alcohol dehydrogenase), performed without method or drug- specific calibration, without matrix-matched quality control material, or without use of stable isotope or other universally recognized internal standard(s) for each drug, drug metabolite or drug class per specimen; qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes Alcohol and/or drug assessment Behavioral health screening to determine eligibility for admission to treatment program Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs Behavioral health counseling and therapy, per 15 minutes Alcohol and/or drug services; group counseling by a clinician Alcohol and/or drug services; case management Alcohol and/or drug services; crisis intervention (outpatient) Alcohol and/or drug services; subacute detoxification (hospital inpatient) Alcohol and/or drug services; acute detoxification (hospital inpatient) Alcohol and/or drug services; subacute detoxification (residential addiction program inpatient) Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) Alcohol and/or drug services; subacute detoxification (residential addiction program outpatient) Alcohol and/or drug services; acute detoxification (residential addiction program outpatient) Alcohol and/or drug services; ambulatory detoxification Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting) Behavioral health; residential (hospital residential treatment program), without room and board, per diem Behavioral health; short-term residential (nonhospital residential treatment program), without room and board, per diem Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program) Alcohol and/or drug training service (for staff and personnel not employed by providers) Page 19 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services HCPCS Codes H0022 H0033 H0034 H0035 H0047 H0048 H0049 H0050 H1000 H1001 H1002 H1003 H1004 H2000 H2010 H2011 H2012 H2013 H2017 H2018 H2025 H2027 H2034 H2035 H2036 J0570 J0571 J0572 J0573 J0574 J0575 J2310 J2315 J3411 S0109 Alcohol and/or drug intervention service (planned facilitation) Oral medication administration, direct observation Medication training and support, per 15 minutes Mental health partial hospitalization, treatment, less than 24 hours Alcohol and/or other drug abuse services, not otherwise specified Alcohol and/or other drug testing: collection and handling only, specimens other than blood Alcohol and/or drug services, brief intervention, per 15 minutes Alcohol and/or drug services, brief intervention, per 15 minutes Prenatal care, at-risk assessment Prenatal care, at-risk enhanced service; antepartum management Prenatal care, at risk enhanced service; care coordination Prenatal care, at-risk enhanced service; education Prenatal care, at-risk enhanced service; follow-up home visit Comprehensive multidisciplinary evaluation Comprehensive medication services, per 15 minutes Crisis intervention service, per 15 minutes Behavioral health day treatment, per hour Psychiatric health facility service, per diem Psychosocial rehabilitation services, per 15 minutes Psychosocial rehabilitation services, per diem Ongoing support to maintain employment, per 15 minutes Psychoeducational service, per 15 minutes Alcohol and/or drug abuse halfway house services, per diem Alcohol and/or other drug treatment program, per hour Alcohol and/or other drug treatment program, per diem Buprenorphine implant, 74.2 mg Buprenorphine, oral, 1 mg Buprenorphine/naloxone, oral, less than or equal to 3 mg buprenorphine Buprenorphine/naloxone, oral, greater than 3 mg, but less than or equal to 6 mg buprenorphine Buprenorphine/naloxone, oral, greater than 6 mg, but less than or equal to 10 mg buprenorphine Buprenorphine/naloxone, oral, greater than 10 mg buprenorphine Injection, naloxone HCl, per 1 mg Injection, naltrexone, depot form, 1 mg Injection, thiamine HCl, 100 mg Methadone, oral, 5 mg ICD-10-CM Diagnosis Codes that Support Coverage Criteria + Indicates a code requiring an additional character Page 20 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services - ICD 10 CM - Code F10.10 through F19.99. O98.711 through O98.73 O99.320 through O99.325 T40.0X1+ through T40.996+ T51.0X1+ through T51.94X+ Z21 Z71.41 Z71.51 Z71.9 Mental and behavioral disorders due to psychoactive substance use. Human immunodeficiency virus [HIV] disease complicating pregnancy Drug use complicating pregnancy, childbirth, and the puerperium Poisoning by, adverse effect of and underdosing of narcotics and psychodysleptics [hallucinogens] Toxic effects of alcohol Asymptomatic human immunodeficiency virus [HIV] infection status Alcohol abuse counseling and surveillance of alcoholic Drug abuse counseling and surveillance of drug abuser Counseling, unspecified Reviews, Revisions, and Approvals New policy. Revised background to clarify that immunoassays are able to detect low concentrations of a drug with a high degree of sensitivity but lack some specificity. Revisions and Addition of Peer Support Services Revised policy to state that HCPCS codes G0482 & G0483 are not medically necessary, and to reflect a 10-day post-collection authorization period. Updated coding tables to include 80367, 80368, 80369, 80370, 80372, and 80373. Revised I.A.1 from “unless no reliable test is available” to “unless no reliable test is in existence” for clarification. References reviewed and updated. Added Appendix A copied from CP.MP.50, Outpatient Testing for Drugs of Abuse Revised description to include Medicare, revised policy / criteria section by moving the policy and criteria section to the correct formatting on the template, added criteria content to reflect age, diagnosis, and appendix reference, moved ASAM LOC criteria after the background section, added content to the background section to update the definition of a substance use disorder, amended “role of medication-assisted treatment (MAT) and Approval Date Revision Date 12/05/18 03/19 08/30/19 05/19 05/19 06/19 11/19 11/19 11/19 11/19 Page 21 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services Reviews, Revisions, and Approvals Revision Date Approval Date removed “detox” and added “maintenance”, updated Categories of Medication section to clarify used to support abstinence and recovery, updated medications used to treat overdose and withdrawal states, changed “detox” to “withdrawal”, included administration of B1 (Thiamine), revised Medications Used to Maintain Abstinence section – added Acamprosate medication protocol under Naltrexone section, changed “alcoholic patients” to “treating alcohol use disorder”, updated content to reflect current clinical terminology, updated dosing and route of administration under Naltrexone, updated Opioids section – changed opiates to opioids, updated administration protocol under Methadone, updated administration protocol under Buprenorphine, under alcohol section – updated Disulfiram administrative protocol, under Additional MAT Considerations – added content to reflect participants in treatment planning, under MAT in Specific Populations – expanded content to reflect treatment standards regarding adolescents and woman who become pregnant, under Level of Care Guidelines – moved section to the correct formatted section in the template, added sentence to clarify application of ASAM guidelines, changed detoxification to withdrawal, removed Appendix A – Daily Testing Section and Appendix B – Toxicology Screening Guidelines. Added Opioid Educational Tools Repository to References Revised HCPSC Code description for G0396 and G0397 Annual Review. References reviewed and updated. Removed duplicate references. Removed “American Society of Addiction Medicine. Public Policy Statement on Drug Testing as a Component of Addiction Treatment and Monitoring Programs and in Other Clinical Settings. Revised October 2010 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2005. (Treatment Improvement Protocol (TIP) Series, No. 43.),” as the policy statement is archived and no longer considered active ASAM policy. Added updated statistics to Background Section. Removed reference Wilfong A. Seizures and epilepsy in children: Initial treatment and monitoring. In: UpToDate, Nordli DR (Ed), UpToDate, Waltham, MA. Accessed 11/5/2020 as it does not applicable to policy content. Update. Changes in formatting were made to pages 6-23. Annual Review. Changed policy title to “Substance Use Disorder Treatment and Services” from “Substance Use Disorders.” References, CPT codes, HCPCS codes, and ICD-10-CM codes, and ASAM levels with corresponding treatments (therapeutic and medication) reviewed with updates. Changed title to Substance Use Disorders from Substance Use Disorder. Changed Cenpatico Behavioral Health to Centene Advanced Behavioral Health (CABH) and CBH to CABH. Added ASAM to reference section. Deleted “level of Care Guideline (ASAM) that outline objective Page 22 of 28 1/20 9/20 11/20 2/20 11/20 11/21 11/21 Revision Date Approval Date CLINICAL POLICY Substance Use Disorder Treatment and Services Reviews, Revisions, and Approvals and evidence-based criteria to standardize coverage determinations and utilization management (UM) practices whose BH UM function has been delegated to CBH”; “are designed for patients 13 year of age and older” and “presenting with a predominant symptom of SUD” from Policy/Criteria section. Changed the sentence “The basic principles of this care are the following:” in the Background section to “The ASAM Criteria guiding principles of this care are the following:” The word “first” was deleted from 5. Least restrictive: Consistent with other medical treatment, less restrictive medically necessary treatment options should be considered when these less restrictive options are considered both equally safe and equally effective compared to higher levels of care.” “MAT is not considered standard of care for substance use disorder treatment” changed to “MAT is considered the standard of care for opioid and other substance use disorders.” CIWA-R was corrected to CIWA-Ar. “Rehabilitation Phase of” was removed from “There now exists a strong evidence base for the use of medication to maintain abstinence and support recovery during SUD Treatment.” Removed “who have repeatedly failed to sustain abstinence despite prior completion of rehabilitation treatment” from “Opioids: This should be offered as part of the treatment planning options to opioid use disorder patients.” Deleted “All these drug classes should be covered at parity with treatments for other medical conditions. “Fail-first” policies with regards to MAT are not considered standard of care and are not recommended.” Deleted “guidelines” from “The ASAM Criteria will be applied upon admission to, assessment of need for continued care, and discharge from each level of care.” Deleted “Historically, addiction treatment has relied heavily on episodic treatment, such as inpatient withdrawal and 30-day rehabilitation with variable adherence to best practices” from Level of Care Guidelines section. In same section, changed “Centene’s level of Care Guidelines outline objective and evidence-based criteria to standardize coverage determinations and utilization management (UM) practices for Centene- Affiliated health plans whose BH UM function has been delegated to Centene Advanced Behavioral Health (CABH)” to “Centene uses ASAM criteria, Level of Care Guidelines and other evidence based guidelines to outline objective and evidence-based criteria to standardize coverage determinations and utilization management (UM) practices for Centene- affiliated health plans whose BH UM function has been delegated to Centene Advanced Behavioral Health (CABH).” Changed “Review Date” in policy header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.” Continued review based on Clinical Policy Subcommittee recommendations; Aligned with current ASAM Level of Care Guidelines; Added Observation Level, Opioid Treatment Programs, and Peer Recovery Support Services. 4/22 4/22 Page 23 of 28 Revision Date 5/22 Approval Date 6/22 12/22 12/22 CLINICAL POLICY Substance Use Disorder Treatment and Services Reviews, Revisions, and Approvals Title of policy changed to SUD Treatment and Services to align with the clinical policy maintained on the Clinical Policy SP Site; Continued review based on Clinical Policy Subcommittee recommendations; Grammatical changes made. Added “Plans managed by CABH may require the use of other evidence-based guidelines, both instead of the ASAM Criteria or in addition to the ASAM Criteria. Examples of these guidelines include, but are”, removed “may also be applied to determine the medical necessity of SUD treatment.” and “may also be applied to determine the medical necessity of SUD treatment.” to Policy/Criteria. Replaced “The ASAM Criteria with “The basic six principles of this care, which aligns with relevant” in Background. Added “available to the member and when these options are” to Background #5. Added “and safe housing including” and “other” in ASAM Criteria Level Of Care Guidelines. Added “adults and” to “Level 3.7 is appropriate for adults and adolescents with co-occurring psychiatric disorders or symptoms that hinder their ability to successfully engage in SUD treatment in other settings.” under ASAM Level 3.7: Medically Monitored Inpatient Programs (Intensive for adults; High Intensity for adolescents). Under Observation, replaced “falls between ASAM Criteria Level of Care Guidelines” with “is not described as a discreet level of care in the ASAM criteria, however, the Criteria does recognize that some inpatient providers offer this service.”. Added “for Adults” to “This level of care is also referred to as clinically managed high (for Adults) or medium (for Adolescents) intensity residential services and is considered ASAM Level 3.5.”, added “Clinical” to “Clinical Services are provided 24 hours/day, 7 days/week in a facility licensed for residential SUD treatment.” and added bullet points “The intensity of nursing care and observation is sufficient to meet the patient’s needs.” and “Biomedical enhanced services are delivered by appropriately credentialed medical staff, who are available to assess and treat co-occurring biomedical disorders.” under ASAM Level 3.5: Clinically Managed Residential Programs (High Intensity for adults, Medium Intensity for adolescents). Added “structured recovery residence environment, staffed 24 hours a day, which provides sufficient stability to prevent or minimize relapse or continued use.” and removed “supervised living residence” to/from sentence 1 of ASAM Level 3.1: Clinically Managed Low-Intensity Residential Programs. Ad-hoc review. Edited policy statement I. to note that it applies to health plans affiliated with Centene Corporation as well as CABH. Replaced all instances of “dashes (-)” in the CPT codes with the word “through”. Replaced all instances of “dashes (-) in page numbers to the word “to”. Page 24 of 28 CLINICAL POLICY Substance Use Disorder Treatment and Services