Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

High-Tech Imaging: After February 28, 2021, eviCore will no longer administer high tech imaging and nuclear medicine for QualChoice. Effective March 1, 2021, those services will be administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 09/18/1995 Title: Detoxification
Revision Date: 04/01/2018 Document: BI073:00
CPT Code(s): F10.230 – F10.239, F11.23, F13.230 – F13.239, F14.23, F15.23, F19.230 – F19.239
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Treatment of the medical complications of acute drug and alcohol withdrawal is covered as a medical benefit, and is subject to all the stipulations and limitations related to medical benefits.

Treatment of drug or alcohol dependency (including withdrawal from acute intoxication, where the withdrawal has no medical complications or consequences) is covered under the mental health benefit and is subject to the limitations of that benefit (see BI273).

Effectiveness for Ultra-rapid detoxification (UROD) as a clinical detoxification treatment and for all other indications has not been established.  QualChoice considers UROD as experimental and investigational and is therefore not covered.  

Medical Statement

Acute drug and alcohol detoxification services (medical management of the withdrawal syndrome) are distinct from drug and alcohol treatment and are eligible for coverage consistent with other medical services. The contracts and provisions of the medical benefit apply.

 

Determination of medical necessity for either involuntary (emergency admission, self directed or through third party intervention) or voluntary (pre-authorized as necessary prior to treatment) admission is based on the need for medical management of the withdrawal syndrome or any concomitant medical condition which might itself require hospitalization as determined by a Plan physician, and as found to be medically necessary by a QualChoice/QCA Medical Director.  Examples include:

 

  • Disorientation or an altered level of consciousness
  • A history of recent seizures
  • Any asymmetric or focal neurologic findings
  • Abnormal vital signs
  • Hemorrhage from any site or petechiae
  • New jaundice or ascites
  • Uncontrolled emesis
  • A level of agitation or intoxication that prohibits satisfactory assessment
  • Depression with risk of suicide

Limits

The standard length of stay (LOS) for alcohol detoxification is 72 hours. Detoxification from long acting barbiturates may take longer. Detoxification from narcotic addiction frequently does not require inpatient care.  Extensions should be reviewed to determine whether services being received are for detoxification or treatment of drug dependency. 

 

Detoxification is not always followed by treatment nor do all patients entering treatment programs require detoxification.  Patients who are severely intoxicated but who do not have a medical complication should be detoxified in a mental health facility rather than an acute hospital setting.

 

The distinction between medical detoxification and mental health treatment needs to be made for appropriate application of member and provider contract provisions.


Reference

Addendum:

1.     Effective 03/01/2017: Added clarification and codes requiring medical record review to determine if processed as medical or mental health benefit.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.