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Coverage criteria policies

Chemical health services

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

All chemical health residential, partial hospital programs and outpatient services with room and board require prior authorization.

Coverage

Indications that are covered

Chemical Health Treatment

Chemical Health Services are generally covered subject to the indications listed below and per your plan documents.

HealthPartners follows the American Society of Addiction Medicine (ASAM) Latest Edition of Patient Placement Criteria. Please contact the Behavioral Health Department at 952-883-7501 for a copy.

All criteria below must be met to meet criteria for chemical health services.

  1. A chemical health assessment completed in the last 30 days by a licensed alcohol and drug chemical health professional or comparably licensed professional is submitted.
  2. The assessment identifies a DSM-5 substance related disorder diagnosis.
  3. The assessment recommends the requested level of care/ treatment.
  4. The level of intensity and duration of treatment matches the level of complexity of the clinical situation.
  5. The ASAM coverage criteria for one of the following are met.
    1. ASAM Level 4 –Medically Managed Intensive Inpatient
    2. ASAM Level 3.7 –Medically Monitored Intensive Inpatient Services (Adult Criteria)
    3. ASAM Level 3.7 Medically Monitored High Intensity Inpatient Services (Adolescent
    4. ASAM Level 3.5 – Clinically Managed High Intensity Residential Services (Adult Criteria)
    5. ASAM Level 3.5 – Clinically Managed Medium Intensity Residential Services (Adolescent Criteria)
    6. ASAM Level 3.3 –Clinically Managed Population – Specific High Intensity Residential Services (Adult Criteria only)
    7. ASAM Level 3.1 – Clinically Managed Low Intensity Residential Services
    8. ASAM Level 2.5 –Partial Hospitalization Services
    9. ASAM Level 2.1 –Intensive Outpatient Services
    10. ASAM Level 1 – Outpatient Services

Urine Drug Testing During Treatment

Urine drug tests during chemical health treatment are covered subject to the indications listed below and per your plan documents.

Urine drug tests are covered during a course of treatment when all of the following conditions are met:

  1. Provided no more than 1x per seven days of treatment, and
  2. Performed by a lab available under the terms of the member’s plan, and
  3. Documentation in the patient’s medical record includes all of the following:
    1. A copy of the written order(s) for drug screens by the treating physician;
    2. Medical necessity for performing qualitative and/or quantitative drug screens as documented by the ordering physician based on the clinical and medical status of the patient and by meeting one of the following:
      1. The patient presents with suspected prescription drug over use, or
      2. Assessment of abstinence before initiation of a drug therapy known to produce withdrawal symptoms is needed, or
      3. There is suspicion of continued substance abuse by a patient in treatment for substance abuse.
    3. A copy of the patient’s plan of care that includes the need for the tests and proposed treatment modifications dependent on the urine drug test result;
    4. A copy of prior lab results with documentation that the results were reviewed by the attending practitioner and documentation of the subsequent treatment plan modifications

Indications that are not covered

Services that are not medically necessary are excluded from coverage. Services that are not medically necessary include, but are not limited to, services that are inconsistent with the medical standards and accepted practice parameters of the community and services that are inappropriate, in terms of type, frequency, level, setting, and duration, to the member’s diagnosis or condition

Chemical dependency treatment which exceeds the level of treatment intensity required based on the member’s clinical treatment needs.

Performance of a drug screen is not medically reasonable and/or necessary for the following:

  1. When routinely performed as part of a physician’s protocol for treatment in absence of any of the above indications.
  2. When performed for the sole purpose of validating observable signs of intoxication.
  3. When the patient is not in an active phase of substance abuse treatment
  4. All fees associated with specimen collection and lab result reports as they are included in the lab test payment and not billed separately.
  5. Non-medically based purposes and/or legal purposes (i.e., court-ordered drug screening, forensic examinations), or administrative or social service agency investigations, proceedings or monitoring
  6. Employment related
  7. Enrollment in school or the military
  8. Administrative or social service agency investigations, proceedings or monitoring
  9. Testing for parents related to divorce/child custody cases
  10. Sports or recreational purposes

Definitions

American Society of Addiction Medicine (ASAM)

  • The ASAM Patient Placement Criteria is the most widely used and comprehensive national guidelines for placement, continued stay and discharge of patients with alcohol and other drug problems.
  • The ASAM Patient Placement Criteria provides two sets of guidelines, one for adults and one for adolescents, and five broad levels of care for each group. The levels of care are:
    • Level 0.5 - Early Intervention
    • Level 1 - Outpatient Treatment
    • Level 2 - Intensive Outpatient and Partial Hospitalization
    • Level 3 - Residential/Inpatient Treatment
    • Level 4 - Medically-Managed Intensive Inpatient Treatment.
  • Within these broad levels of service is a range of specific levels of care.

http://www.asam.org/publications/the-asam-criteria/about/

Chemical Health Residential Services include residential services with primary treatment and chemical health lodging. Excluded are inpatient hospital based services and community detoxification services and low or moderate intensity residential services

Urine Drug Testing: a standardized method of detecting the presence of drugs in the urine as a means to monitor the use of non-prescribed drugs or misuse of prescribed drugs. These include qualitative or quantitative testing

Confirmatory Urine Drug Test: a more sensitive and specific quantitative or qualitative test which may be performed after a positive screening test (G6058)

Qualitative Urine Drug Test: immunoassay test that detects the absence or presence of a drug or its metabolites in the urine and is used as a rapid turn-around screening test. Because of the potential for false positives, positive results may be followed by confirmatory testing. These tests do not indicate specific levels.

Quantitative Urine Drug Test: measures the amount and concentration of a specific drug or metabolite in the urine and are used to confirm the presence of a specific drug identified by a screening test. They can also be used to identify certain synthetic or semisynthetic opioids that cannot be detected by immunoassay testing. Gas chromatography/mass spectrometry is considered the standard.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The services associated with these codes are covered under the conditions listed above:

Code

Treatment

H2036

Alc &/or other drug treatment program, per diem

Rev codes

1002 , 1003

H0035

Partial Hospitalization Program

Rev Codes

912

H2035

OP Treatment

Rev Codes

906, 913, 944, 945, 953

H2034

Alc &/or other drug abuse halfway house services, per diem

Code

Qualitative Lab Code Description

80184

Assay of Phenobarbital

80188

Assay of Primidone

81003

Urinalysis Auto w/o Scope

82542

Column Chromatography Qual

82570

Assay of Urine Creatinine

80305

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (eg., dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service

80306

Drug test(s), presumptive, any number of drug classes, any number of devices

or procedures (eg., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when performed, per date of service

80307

Drug test(s), presumptive, any number of drug classes, any number of devices or procedures, by instrument chemistry analyzers (eg., utilizing immunoassay [eg., eia, elisa, emit, fpia, ia, kims, ria]), chromatography (eg, gc, hplc), and mass spectrometry either with or without chromatography, (eg, dart, desi, gc-ms, gc-ms/ms, lc-ms, lc-ms/ms, ldtd, maldi, tof) includes sample validation when performed, per date of service

Code

Quantitative Lab Code Description

G0480

Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 1-7 drug class(es), including metabolite(s) if performed

G0481

Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 8-14 drug class(es), including metabolite(s) if performed

G0482

Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 15-21 drug class(es), including metabolite(s) if performed

G0483

Drug test(s), definitive, utilizing drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), qualitative or quantitative, all sources(s), includes specimen validity testing, per day, 22 or more drug class(es), including metabolite(s) if performed

80299

Quantitation of drug, not elsewhere specified

80320

Alcohols

80321

Alcohol biomarkers; 1 or 2

80322

Alcohol biomarkers; 3 or more

80324

Amphetamines; 1 or 2

80325

Amphetamines; 3 or 4

80326

Amphetamines; 5 or more

80335

Antidepressants, tricyclic and other cyclicals; 1 or 2

80336

Antidepressants, tricyclic and other cyclicals; 3-5

80337

Antidepressants, tricyclic and other cyclicals; 6 or more

80338

Antidepressants, not otherwise specified

80339

Antiepileptics, not otherwise specified; 1-3

80340

Antiepileptics, not otherwise specified; 4-6

80341

Antiepileptics, not otherwise specified; 7 or more

80342

Antipsychotics, not otherwise specified; 1-3

80343

Antipsychotics, not otherwise specified; 4-6

80344

Antipsychotics, not otherwise specified; 7 or more

80345

Barbiturates

80346

Benzodiazepines; 1-12

80347

Benzodiazepines; 13 or more

80348

Buprenorphine

80349

Cannabinoids, natural

80350

Cannabinoids, synthetic; 1-3

80351

Cannabinoids, synthetic; 4-6

80352

Cannabinoids, synthetic; 7 or more

80353

Cocaine

80354

Fentanyl

80355

Gabapentin, non-blood

80356

Heroin metabolite

80357

Ketamine and norketamine

80358

Methadone

80359

Methylenedioxyamphetamines (MDA, MDEA, MDMA)

80360

Methylphenidate

80361

Opiates, 1 or more

80362

Opioids and opiate analogs; 1 or 2

80363

Opioids and Opiate analogs; 3 or 4

80364

Opioids and Opiate analogs; 5 or more

80365

Oxycodone

80366

Pregabalin

80367

Propoxyphene

80368

Sedative hypnotics (non-benzodiazepines)

80369

Skeletal muscle relaxants; 1 or 2

80370

Skeletal muscle relaxants; 3 or more

80371

Stimulants, synthetic

80372

Tapentadol

80373

Tramadol

80374

Stereoisomer (enantiomer) analysis, single drug class

80375

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3

80376

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4-6

80377

Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more

83992

Quantitative analysis of phencyclidine (PCP)

84311

Spectrophotometry, analyte not elsewhere specified

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References:

  1. American Society of Addiction Medicine (ASAM) Latest Edition of Patient Placement Criteria

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Policy activity

  • 08/23/2017 - Date of origin
  • 07/19/2018 - Effective date
Review date
  • 08/2018
Revision date
  • 07/19/2018

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