Non-Hospital Medical Detox

Description of Procedure or Service

Residential care programs for the treatment of substance-related provide 24-hour care with trained counselors to stabilize multidimensional danger. Danger in the context of substance use disorder treatment includes the strong probability of continued substance use or relapse, the likelihood of adverse consequences related to use (e.g., driving while intoxicated), and the likelihood that the adverse events will occur in the near future, that is in hours to days rather than in weeks to months. Multidimensional factors may include withdrawal symptoms; biomedical complications; or emotional, cognitive, or behavioral concerns.

Residential care is intended for patients who need around-the-clock behavioral care but do not need the high level of physical security and frequency of psychiatric and medical intervention available on an inpatient unit. Specialty centers providing residential treatment for substance-related disorders may do so in therapeutic rehabilitation facilities, therapeutic communities, or residential treatment centers; and withdrawal management may be provided in a variety of 24-hour social setting environments.

Substance-related disorders are chronic conditions with recurrent cycles of misuse, recovery, and often, relapse. Periodic management of intoxication and withdrawal (collaboratively termed withdrawal management) is a common component of the treatment of substance-related disorders based on their chronic and relapsing course.

***Note: This Medical Policy is complex and technical. For questions concerning the technical language and / or specific clinical indications for its use, please consult your physician.

Policy

BCBSNC will provide coverage for Non-Hospital Medical Detox when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

Benefits Application

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy.

When Non-Hospital Medical Detox is covered

Non-Hospital Medical Detox is considered medically necessary for one or more of the following:

Admission for Non-Hospital Medical Detox for Adults is considered medically necessary for ALL of the following:

• Individual risk or severity of substance-related disorder is appropriate to proposed level of care for withdrawal management, and performance in 24-hour setting (residential care environment) is appropriate, as indicated by ALL of the following: 
  • Signs of withdrawal are present, or risk of development is imminent. o Individual is judged not to be at risk of withdrawal beyond scope of residential care (e.g., no severe or complicated withdrawal). 
  • 24-hour residential care treatment environment is needed, as indicated by one or more of the following: 
    • Recovery environment is dangerous and patient lacks skills to remain safe outside of around-the-clock treatment program. 
    • Withdrawal management at lower level of care is not feasible or is inappropriate (e.g., less intensive level of care is unavailable or is not suitable to individual condition or treatment history). 
• Treatment services available at proposed level of care are necessary to meet individual needs and one or more of the following: 
  • Specific condition related to admission diagnosis is present and judged likely to further improve at proposed level of care. 
  • Specific condition related to admission diagnosis is present and judged likely to deteriorate in absence of treatment at proposed level of care. 
  • Individual is receiving continuing care (e.g., transition of care from more or less intensive level of care). 
• Situation and expectations are appropriate for residential care for adult, as indicated by ALL of the following: 
  • Recommended treatment is necessary, appropriate, and not feasible at lower level of care (e.g., less intensive level is unavailable or not suitable for patient condition or history). 
  • Individual is willing to participate in treatment within highly structured setting voluntarily (or attend due to court order). 
  • There is no anticipated need for physical restraint, seclusion, or other involuntary control (e.g., patient not actively violent). 
  • Medical or nursing care services to address primary admission diagnosis are available, as indicated by 1 or more of the following:
    • No anticipated need for around-the-clock medical or nursing monitoring (i.e., comorbid medical, psychiatric, or behavioral conditions are absent or are of minimal severity, and are not expected to interfere with recovery)
    • Active (but not around-the-clock) monitoring of patient by staff needed, and medical or nursing care can easily be provided if need arises (i.e., comorbid medical, psychiatric, or behavioral conditions have potential to distract from treatment) 
    • Around-the-clock medical or nursing monitoring needed, but intensive treatment and resources of licensed hospital are not anticipated (i.e., due to severity of primary admitting diagnosis, or presence of active comorbid medical, psychiatric, or behavioral conditions that are distracting from treatment) 
  • Biopsychosocial stressors potentially contributing to clinical presentation (e.g., comorbidities, illness history, environment, social network, ability to cope, and level of engagement) have been assessed and are absent or manageable at proposed level of care. 

Admission for Non-Hospital Medical Detox for Child or Adolescent 

• Individual risk or severity of substance-related disorder is appropriate to proposed level of care, as indicated by the presence of 1 or more of the following: 
  • Substance-related disorder with active symptoms is present and requires residential treatment, as indicated by ALL of the following: 
    • Signs or symptoms of withdrawal requiring acute management, if present, are manageable / treatable at proposed level of care. 
    • Potential for relapse that places patient at risk of immediate danger outside of treatment in residential care. 
    • Barrier to change that places individual at risk of immediate danger outside of residential care 
    • Highly stressful or minimally supportive environment (e.g., environment is dangerous and individual needs 24-hour, highly structured care setting to develop coping skills and achieve recovery) 
    • Moderately severe psychiatric, behavioral, or other comorbid conditions assessed for and are absent or manageable / treatable at proposed level of care, as indicated by 1 or more of the following: 
      • Psychiatric symptoms, including 1 or more of the following: 
        • Hallucinations (child or adolescent), Delusions (child or adolescent), or other Positive symptoms (child or adolescent) 
        • Negative symptoms (child or adolescent), including social or emotional withdrawal or lack of self-initiated behavior or movement 
        • Mania (child or adolescent) 
        • Depressive symptoms (child or adolescent) 
        • Anxiety (child or adolescent) 
        • Hyperactivity or inattention (child or adolescent) 
        • Obsessions or compulsions (child or adolescent) 
        • Personality disorders / maladaptive personality traits 
        • Other psychiatric symptoms related to underlying psychiatric disorder or underlying comorbid condition having a negative impact on primary psychiatric disorder 
      • Comorbid biomedical or developmental condition 
      • Comorbid substance use disorder 
      • Cognitive or memory impairment 
      • Impaired impulse control, judgment, or insight 
      • Emotional or behavioral disturbances impacting symptoms or function, including 1 or more of the following: 
        • Externalizing symptoms (e.g., angry outbursts, physical or verbal aggression, oppositional defiant traits, agitation, anxiety, or other disruptive behaviors) 
        • Internalizing symptoms (e.g., sulking, rumination, anhedonia, dysphoria, apathy) 
        • Evidence of severely diminished ability to assess consequences of own actions (e.g., acts of severe property damage) 
        • High levels of family conflict or interpersonal conflict 
        • Escalating relapse behaviors  
        • Other emotional or behavioral disturbance relevant to clinical presentation 
      • Serious dysfunction in daily living for child or adolescent is present, as indicated by 1 or more of the following: 
        • Serious deterioration in interpersonal interactions (e.g., impulsive, or abusive behaviors) 
        • Significant withdrawal and avoidance of almost all social interaction 
        • Consistent failure to achieve self-care as appropriate to age or developmental level o Serious disturbance in vegetative status (e.g., weight change, sleep disruption) threatening physical function 
        • Inability to perform adequately in school (including specialized setting) due to disruptive or aggressive behavior 
        • Severely diminished ability to assess consequences of own actions (e.g., acts of severe property damage) 
        • Other evidence of serious dysfunction 
• Danger to self for child or adolescent is present due to 1 or more of the following:
  • Command auditory hallucinations contributing to risk for suicide or serious harm to self 
  • Individual has persistent thoughts of suicide or serious Harm to self that cannot be adequately monitored or treated at lower level of care as indicated by 1 or more of the following: 
    • Necessary child or adolescent behavioral health care (such as required provider or lower level of care) not available or insufficient 
    • Conflict in family environment or other inadequacy in individual support system 
    • Individual characteristics, such as moderately severe to severely Impaired impulse control, judgment, or insight; moderate to moderately severe Mania (child or adolescent) or unreliability 
    • Indication or report of significant physical or sexual risky behavior with Impaired impulse control, judgment, or insight that significantly endangers self 
  • Danger to others for child or adolescent is present due to 1 or more of the following: 
    • Command auditory hallucinations or paranoid delusions contributing to risk for homicide or serious harm to another 
    • Individual has persistent thoughts of homicide or serious Harm to another that cannot be adequately monitored or treated at lower level of care, as indicated by 1 or more of the following: 
      • Necessary child or adolescent behavioral health care (such as required provider or lower level of care) not available or insufficient 
      • Conflict in family environment or other inadequacy in individual support system 
      • Individual characteristics, such as moderately severe to severely Impaired impulse control, judgment, or insight; moderate to moderately severe Mania (child or adolescent) or unreliability 
      • Indication or report of significant physical or sexual aggression with Impaired impulse control, judgment, or insight that significantly endangers another 
      • Current homicidal ideation with either clearly expressed intentions or past history of carrying out such behavior 
  • Withdrawal management is needed and performance in 24-hour setting (residential care environment) is appropriate, as indicated by ALL of the following: 
    • Signs of withdrawal are present, or risk of development is imminent 
    • Individual is judged not to be at risk of withdrawal beyond scope of residential care (e.g., no severe or complicated withdrawal). 
    • 24-hour residential care treatment environment is needed, as indicated by 1 or more of the following: 
      • Recovery environment is dangerous and individual lacks skills to remain safe outside of around-the-clock treatment program. 
      • Withdrawal management at lower level of care is not feasible or is inappropriate (e.g., less intensive level of care is unavailable or is not suitable to individual condition or treatment history). 
• Treatment services available at proposed level of care are necessary to meet individual needs and 1 or more of the following: 
  • Specific condition related to admission diagnosis is present and judged likely to further improve at proposed level of care. 
  • Specific condition related to admission diagnosis is present and judged likely to deteriorate in absence of treatment at proposed level of care. 
  • Individual is receiving continuing care (e.g., transition of care from more or less intensive level of care). 
• Situation and expectations are appropriate for residential care for child or adolescent, as indicated by ALL of the following
  • Recommended treatment is necessary, appropriate, and not feasible at lower level of care (e.g., less intensive level is unavailable or not suitable for individual condition or history). 
  • Very short-term crisis intervention and resource planning for further care at nonresidential level is unavailable or inappropriate. 
  • Individual is willing to participate (or agrees to participate at direction of parent or guardian, or attend due to court order) in treatment within highly structured setting voluntarily. 
  • There is no anticipated need for physical restraint, seclusion, or other involuntary control for safety (e.g., individual not actively violent). 
  • Medical or nursing care services to address primary admission diagnosis are available, as indicated by 1 or more of the following: 
    • No anticipated need for around-the-clock medical or nursing monitoring (i.e., comorbid medical, psychiatric, or behavioral conditions are absent or are of minimal severity, and are not expected to interfere with recovery 
    • Active (but not around-the-clock) monitoring by individual or staff needed, and medical or nursing care can easily be provided if need arises (i.e., comorbid medical, psychiatric, or behavioral conditions have potential to distract from treatment) 
    • Around-the-clock medical or nursing monitoring needed, but intensive treatment and resources of licensed hospital are not anticipated (i.e., due to severity of primary admitting diagnosis, or presence of active comorbid medical, psychiatric, or behavioral conditions that are distracting from treatment) 
  • Individual has sufficient ability to respond as planned to individual and group therapeutic interventions. 
  • Biopsychosocial stressors potentially contributing to clinical presentation (e.g., comorbidities, illness history, environment, social network, ability to cope, and level of engagement have been assessed and are absent or manageable at proposed level of care. 

Continued care for Non-Hospital Medical Detox for Adult, Child, or Adolescent is considered medically necessary when the initial approval criteria continue to be met. 

When Non-Hospital Medical Detox is not covered

Non-Hospital Medical Detox is considered not medically necessary for one or more of the following:

Non-Hospital Medical Detox is considered not medically necessary when the criteria above is not met.

• Admission for Non-Hospital Medical Detox for adult, child or adolescent is considered not medical necessary for one or more of the following:
  • When the criteria listed above is not met.
  • Higher level of care is indicated (e.g., patient condition has deteriorated, or more intensive supervision is necessary to address clinical needs).
  • Clinical condition indicates need for long-term custodial facility.
  • Individual or guardian refuses treatment.
• Continued care for Non-Hospital Medical Detox for Adults is considered not medically necessary for one or more of the following:
  • Residential care is no longer necessary due to adequate individual stabilization or improvement, as indicated by ALL of the following:
    • Risk status acceptable, as indicated by ALL of the following:
      • Danger to self or others manageable / treatable, as indicated by 1 or more of the following:
        • Absence of thoughts of suicide, homicide, or serious harm to self or to another
        • Thoughts of suicide, homicide, or serious harm to self or to another present but manageable / treatable at available lower level of care
      • Individual and supports understand follow-up treatment and crisis plan.
      • Provider and supports are sufficiently available at lower level of care. 
      • Individual, as appropriate, can participate as needed in monitoring at available lower level of care.
    • Functional status acceptable, as indicated by 1 or more of the following:
      • No essential function is significantly impaired.
      • An essential function is impaired, but impairment is manageable / treatable at available lower level of care.
    • Symptom status acceptable, as indicated by ALL of the following:
      • Symptoms stabilized and may be appropriately treated at available lower level of care
      • No current plan for change in treatment or re-evaluation
    • Medical needs absent or manageable / treatable at available lower level of care, as indicated by ALL of the following:
      • Adverse medication effects absent or manageable / treatable
      • Medical comorbidity absent or manageable / treatable
      • Medical complications absent or manageable / treatable (e.g., complications of eating disorder)
      • Substance-related disorder absent or manageable / treatable
    • Treatment goals for level of care met
    • Addiction treatment and / or withdrawal treatment needs manageable / treatable at available lower level of care.
• Continued care for Non-Hospital Medical Detox for Child or Adolescent is considered not medically necessary for one or more of the following:
  • Residential care is no longer necessary due to adequate individual stabilization or improvement as indicated by ALL of the following:
    • No seizure or other severe withdrawal event for at least 24 hours
    • Risk status acceptable, as indicated by ALL of the following:
      • Danger to self or others manageable / treatable, as indicated by one or more of the following:
        • Absence of thoughts of suicide, homicide, or serious harm to self or to another
        • Thoughts of suicide, homicide, or serious harm to self or to another present but manageable / treatable at available lower level of care
      • Individual and supports understand follow-up treatment and crisis plan. 
      • Provider and supports are sufficiently available at lower level of care. 
      • Individual, as appropriate, can participate as needed in monitoring at available lower level of care.
    • Functional status acceptable, as indicated by 1 or more of the following:
      • No essential function is significantly impaired.
      • An essential function is impaired, but impairment is manageable / treatable at available lower level of care.
    • Symptom status acceptable, as indicated by ALL of the following:
      • Symptoms stabilized and may be appropriately treated at available lower level of care
      • No current plan for change in treatment or re-evaluation
      • Medical needs absent or manageable / treatable at available lower level of care, as indicated by ALL of the following:
      • Adverse medication effects absent or manageable / treatable
      • Medical comorbidity absent or manageable / treatable
      • Medical complications absent or manageable / treatable (egg, complications of eating disorder)
      • Substance-related disorder absent or manageable / treatable
    • Treatment goals for level of care met
    • Addiction treatment and / or withdrawal treatment needs manageable / treatable at available lower level of care.

Policy Guidelines

Non-Hospital Medical Detox requires precertification, prior plan approval, or prior authorization.

Treatment of substance-related disorders, including dependence or withdrawal, nearly always can be conducted in an outpatient setting. Inpatient admission may be needed to manage severe alcohol or sedative withdrawal or to manage behavior in the setting of any substance-related disorder that presents an imminent risk of harm to the patient or others. A narrative review on the inpatient management of opioid use disorder states that hospitalization can serve as an opportunity to address addiction, identify and intervene on psychosocial and mental health barriers, treat substance withdrawal, and propagate harm-reduction strategies. In the absence of imminently life-threatening medical or psychiatric conditions, treatment of patients with substance-related disorders may be delivered in alternative treatment settings, such as residential care, partial hospital programs, or intensive outpatient care.

Billing / Coding / Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: H0010

BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and / or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

Service planning and placement. In: Mee-Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, Provence SM, editors. ASAM Criteria Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013:105-126.

Lee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, Provence SM, editors. ASAM Criteria Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013:174-306.

Matching multidimensional severity and level of function with type and intensity of service. In: MeeLee D, Shulman GD, Fishman MJ, Gastfriend DR, Miller MM, Provence SM, editors. ASAM Criteria Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Carson City, NV: The Change Companies; 2013:69-104.

Drug Misuse Opioid Detoxification. NICE Clinical Guidance CG52 [Internet] National Institute for Health and Care Execellence. 2007 Jul (NICE reviewed 2019) Accessed at: https://www.nice.org.uk/guidance.

Day E, Strang J. Outpatient versus inpatient opioid detoxification: a randomized controlled trial. Journal of Substance Abuse Treatment 2011;40(1):56-66. DOI: 10.1016/j.jsat.2010.08.007.

Substance-related and addictive disorders. In: American Psychiatric Association, editor. Diagnostic and Statistical Manual of Mental Disorders. DSM-5-TR ed. American Psychiatric Association; 2022:543- 666.

Drug Misuse Psychosocial Interventions. NICE Clinical Guidance CG51 [Internet] National Institute for Health and Care Excellence. 2007 Jul (NICE reviewed 2016 Jul) Accessed at: https://www.nice.org.uk/guidance.

Huguet N, Kaplan MS, McFarland BH. Rates and correlates of undetermined deaths among African Americans: results from the National Violent Death Reporting System. Suicide and Life-threatening Behavior 2012;42(2):185-196. DOI: 10.1111/j.1943-278X.2012.00081.x.

Schinka JA, Schinka KC, Casey RJ, Kasprow W, Bossarte RM. Suicidal behavior in a national sample of older homeless veterans. American Journal of Public Health 2012;102 Suppl 1:S147-S153. DOI: 10.2105/AJPH.2011.300436.

Medical Director review 9/2024 Page

Policy Implementation / Update Information

10/1/24 New policy developed. Non-Hospital Medical Detox may be medically necessary when the medical criteria and guidelines above are met. Medical Director review 9/2024. Notification given 10/1/24 for effective date 12/31/24. (tt)