Memorial hermann healthnet providers

MEDICAL MANAGEMENT POLICY

TITLE: Admission Criteria for Outpatient
POLICY NUMBER: MEDM-090-2011
Detoxification Treatment Services
(Pre-Cert Required) Yes x No
EFFECTIVE DATE: 7/1/2011
REVISION DATE:
PAGE: 1 of 4
SUPERSEDES:
POLICY IN COMPLIANCE WITH:

This medical policy is not a guarantee of benefits or coverage, nor should it be deemed as
medical advice. In the event of any conflict concerning benefit coverage, the
employer/member summary plan document (SPD) supersedes this medical policy.

DEFINITIONS: Detoxification is the physiological or medicinal removal of toxic substances
from a living organism, including but not limited to the human body, and additionally can refer
to the period of withdrawal during which an organism returns to homoeostasis after long-term
use of an addictive substance.

INDICATIONS: To provide reasonable procedures regarding admission criteria for outpatient
detoxification treatment services.
POLICY: MHealth (hereinafter referred to as Company) will comply with the recommended
stay period for outpatient detoxification treatment services from five (5) to ten (10) days. This
will be preformed based on the following criteria:
1. The individual is dependent on high doses of sedative hypnotics. 2. The individual has been taking high doses of opiate medications. 3. If the individual is pregnant, she may require longer than 10 days of outpatient 1. The decision of the treating physician 2. The admission criteria for outpatient detoxification treatment services 3. Recommended treatment periods depending on the condition of the patient
These recommendations must be accompanied by the commencement of appropriate utilization
review and discharge planning at the time of admission.
PROCEDURE: The Company will comply with the above policy and the following criteria
when the individual meets the following conditions/diagnosis:

MEDICAL MANAGEMENT POLICY

TITLE: Admission Criteria for Outpatient
POLICY NUMBER: MEDM-090-2011
Detoxification Treatment Services
(Pre-Cert Required) Yes x No
EFFECTIVE DATE: 7/1/2011
REVISION DATE:
PAGE: 2 of 4
SUPERSEDES:
POLICY IN COMPLIANCE WITH:

(1) The diagnosis must meet the criteria for the definition of substance (chemical) dependence,
as detailed in the most current revision of the International Classification of Diseases, or the most
current revision of the Diagnostic and Statistical Manual of Mental Disorders, accompanied by
evidence that some of the symptoms have persisted for at least one (1) month or have occurred
repeatedly over a longer period of time.
(2) Once the diagnostic criteria for substance (chemical) dependency have been met, the
following conditions must also be met:
(A) Category 1: Chemical substance withdrawal. The individual is expected to have a stable
withdrawal from alcohol/drugs.
(B) Category 2: Medical functioning. The patient must meet all the criteria in clauses (i)-(viii)
of this subparagraph.
(i) Patient has no history of recent seizures or past history of seizures on withdrawal.
(ii) Lack clinical evidence of altered mental state as manifested by:
(I) Disorientation to self
(II) Alcoholic hallucinations
(III) Toxic psychosis
(IV) Altered level of consciousness, as manifested by clinically significant obtundation,
stupor, or coma.
(iii) The symptoms are not due to a general medical condition.
(iv) Absence of any presumed new asymmetric and/or focal findings (i.e., limb weakness,
clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema,
or localized cerebellar dysfunction, as reflected in asymmetrical limb coordination).
(v) The patient must have vital signs interpreted by a physician to be stable, without a
previous history of complications from acute chemical substance withdrawal, and judged to be
free of a physician-determined health risk.
(vi) The patient has no evidence of a coexisting serious injury or systemic illness, newly
discovered or progressive in nature.
(vii) Absence of serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest
pains, arrhythmia or hypotension.
(viii) The patient's clinical condition allows for a comprehensive and satisfactory assessment
of items cited in clauses (i)-(vii) of this subparagraph and paragraphs (A)-(D).
(C) Category 3: family, social, academic dysfunction. The patient must meet the criteria of at
least one clause out of clauses (i)-(iv) of this subparagraph.
MEDICAL MANAGEMENT POLICY

TITLE: Admission Criteria for Outpatient
POLICY NUMBER: MEDM-090-2011
Detoxification Treatment Services
(Pre-Cert Required) Yes x No
EFFECTIVE DATE: 7/1/2011
REVISION DATE:
PAGE: 3 of 4
SUPERSEDES:
POLICY IN COMPLIANCE WITH:
(i) The patient's social system and significant others are supportive of recovery to the extent that the patient can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the patient's addiction. (ii) The patient's family and/or significant others are willing to participate in the outpatient detoxification treatment program. (iii) The patient may or may not have a primary or social support system to assist with immediate recovery, but has the social skills to obtain such a support system and/or to become involved in a self-help fellowship. (iv) The patient's living environment should be considered as a factor. An individual living in an environment where licit or illicit mood-altering substances are being used may not be a candidate for this level of care. (D) Category 4: emotional/behavioral status. The patient must meet all the criteria under clauses (i)-(vii) of this subparagraph. (i) Patient is coherent, rational and oriented for treatment. (ii) Mental state of the patient does not preclude the patient's ability to: (I) Comprehend and understand the materials presented; and (II) Participate in the outpatient detoxification treatment process. (iii) There is documentation that the patient expresses an interest to work toward outpatient detoxification treatment goals. (iv) Patient has no neuropsychiatric condition that places him or her at imminent risk of harming self or others (e.g., pathological intoxication, alcohol idiosyncratic intoxication, etc.). (v) Patient has no neurological, psychological or uncontrolled behavior that places him or her at imminent risk of harming self or others (e.g., depression, anguish, mood fluctuations, overreactions to stress, lower stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, negative emotions, anxiety, etc.). (vi) Patient has no documented DSM-IV axis I condition or disorder which, in combination with alcohol and/or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the patient. (vii) The patient has no mental confusion and/or fluctuating orientation. (E) Category 5: recent chemical substance use. The patient must meet the criteria in at least one clause out of clauses (i) and (ii) of this subparagraph. (i) The patient's chemical substance use is excessive, and the patient has attempted to reduce or control it, but has been unable to do so (as long as chemical substances are available). (ii) The patient is motivated to stop using alcohol/drugs, and is in need of a supportive structured treatment program to facilitate withdrawal from chemical substances. MEDICAL MANAGEMENT POLICY

TITLE: Admission Criteria for Outpatient
POLICY NUMBER: MEDM-090-2011
Detoxification Treatment Services
(Pre-Cert Required) Yes x No
EFFECTIVE DATE: 7/1/2011
REVISION DATE:
PAGE: 4 of 4
SUPERSEDES:
POLICY IN COMPLIANCE WITH:

The Company will comply with the following criteria when the member meets the diagnostic
criteria and the conditions under at least (1) or (2) in subsection (b) as follows:
(b) Factors for continued outpatient detoxification treatment services are listed in paragraphs (1)
and (2) of this subsection.
(1) Chemical substance withdrawal complications. The patient must meet the conditions of
subparagraphs (A) or (B) of this paragraph.
(A) Patient, while physically abstinent from chemical substance use, is exhibiting incomplete
stable withdrawal from alcohol/drugs, as evidenced by psychological and physical cravings.
(B) Patient, while physically abstinent from chemical substance use, is exhibiting incomplete
stable withdrawal from alcohol/drugs, as evidenced by significant drug levels.
(2) Psychiatric or medical complications. Documentation in the record indicates an intervening
medical or psychiatric event which was serious enough to interrupt outpatient detoxification
treatment, but the patient is again progressing in treatment.
PROCESS:
The member or provider must contact:
1. The Customer Service department to verify eligibility/benefits. 2. Medical Management to initiate a pre-authorization. 3. Provide clinical information which supports the medical necessity of the requested
CPT, HCPC CODES: Use approved CMS codes for the Admission Criteria for Outpatient
Detoxification Treatment Services rendered must be medically necessary/related and a covered
benefit for the member’s plan.

Source: http://www.mhcommunitybenefitcorp.org/docs/Medical%20Management/Admission%20Criteria%20For%20Outpt%20Detoxification%20Treatment%20Services.pdf