| Effective Date:09/18/1995 |
Title:Detoxification
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| Revision Date:04/01/2018
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Document:BI073:00
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| CPT Code(s):F10.230 – F10.239, F11.23, F13.230 – F13.239, F14.23, F15.23, F19.230 – F19.239
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Public Statement
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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.
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Medical Statement
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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:
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Disorientation or an
altered level of consciousness
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A history of recent
seizures
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Any asymmetric or
focal neurologic findings
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Abnormal vital signs
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Hemorrhage from any
site or petechiae
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New jaundice or
ascites
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Uncontrolled emesis
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A level of agitation
or intoxication that prohibits satisfactory assessment
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Depression with risk
of suicide
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Limits
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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.
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Reference
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Addendum:
1.
Effective 03/01/2017:
Added clarification and codes requiring medical record review to determine if
processed as medical or mental health benefit.
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Application to Products
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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.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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