Comprehensive Behavioral Care, Inc. Level of Care Guidelines Substance Abuse Children/Adolescents

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1 Medical Necessity In considering the appropriateness of any level of care, the four basic elements of Medical Necessity should be met: 1. A diagnosis as defined by standard diagnosis nomenclatures (DSM IV or its equivalent in ICD-9-CM) and an individual treatment plan appropriate for the participant s illness or condition. 2. Can reasonably be expected to restore a Member s condition to a usual and customary level of functioning for that individual 3. Have proven efficacy as defined by standard clinical references and empirical experience; and 4. Are rendered at the most cost-effective and safe level of care (within the health care benefit). 5. Support an abstinence model of treatment. Additionally and as outlined in Medicaid guidelines; 1. Be necessary to protect life, to prevent significant illness or significant disability; 2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient s needs; 3. Be consistent with the generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational; 4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available, statewide; and 5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient s caretaker or the provider. Procedures for Applying UM Criteria are designed to be appropriate for the uncomplicated patient and for the very complete delivery system; they may not be appropriate for the patient with complication or for a delivery system that does not include sufficient alternatives to a particular LOC and a particular patient. Therefore, CompCare considers at least the following factors when applying criteria to a given individual: Page 1 of 18

2 Age Comorbidities; including information obtained in consultation with the Primary Care Physician and/or the Health Plan UM team Complications Progress of treatment Psychological situation Home environment, when applicable The characteristics of the local delivery system available to a particular patient should also be considered: Availability of alternative levels of care, such as intensive outpatient programs, outpatient detoxification programs or residential treatment centers in the service area to support the patient after hospital discharge. Coverage of benefits for alternative levels of care, such as residential treatment centers where needed Ability of local providers to provide all recommended services within the estimated length of stay. When the above listed member and delivery system complications are identified the Care Management staff are directed to seek internal clinical guidance through case management peer review, discussion with the Director of Clinical Services or the physician advisor. Additionally, when the member is seeking detoxification, CompCare Care Management staff are directed to carefully consider member safety related to medical stability by questions that include, but are not limited to: Co-existing medical conditions and PCP treatment and management of medical conditions Member age Past detoxification history Type of treatment facility free standing or within a medical facility Multifamily groups are considered in addition to scheduled family therapy for the individual member and his/her family. Page 2 of 18

3 SUBSTANCE ABUSE OUTPATIENT TREATMENT Organized outpatient treatment for children and adolescents with chemical dependency may be delivered in a wide variety of settings and by addiction treatment staff with a variety of experience and credentials. The services must follow a defined set of policies and procedures or clinical protocols and usually encompass less than six contact hours per week. Individual, group and family sessions may occur with special emphasis on group and family involvement as individually indicated. The treatment is designed to help the young member achieve positive changes in his or her alcohol- or other drug-using behaviors. Areas that have a potential to undermine the goals of treatment or to impair the member s ability to cope with major life tasks without the non-medical use of alcohol or other drugs must be addressed in this treatment. These areas include major familial, attitudinal, behavioral and cognitive issues or beliefs. Treatment interventions and modalities are tailored to engage the members who are at varying levels of developmental maturity. This level of care is appropriate in a variety of circumstances. It may be used as 1) a step down from a more intensive level of care, 2) the initial level of care for a young member, or 3) an option to engage and enhance the motivation of a resistant young member who is not ready to commit to recovery and is in the early stages of change. Treatment at this level of care often requires linkages with other service providers. These may include referrals for psychiatric assessment and treatment, primary care medical assessment and treatment, psychological and/or educational testing for learning disorders, special or alternative education services, family therapies, juvenile justice probation and supervision, foster care support services and other social service agency interventions. For children and adolescents, there is an expectation of face-to-face family meetings and involvement in treatment unless the physician determines this is contra-indicated. Page 3 of 18

4 Admission: Outpatient Treatment 1.Must be met 2. Must meet ALL: A The member is not demonstrating any life-threatening withdrawal symptoms that require acute inpatient detoxification. B The member is not suffering medical/psychiatric complications of his/her substance abuse that would inhibit ability to actively participate in and benefit from participation in the treatment OR is receiving concurrent medical or psychiatric monitoring and is stable. C The member is able to maintain abstinence or control use and pursue recovery or motivational goals and needs limited support. D Must meet medical necessity The member s family and environment can support recovery with limited assistance. E F The member suffers from minimal to mild impairment in social, medical, family and/or work functioning secondary to substance abuse. The member demonstrates an interest in working toward the goal of rehabilitation, but needs motivating and monitoring strategies to strength readiness OR the member is in early stages of change and a more intensive level of care could be lead to passive compliance, increased conflict, withdrawal from treatment or be counterproductive. Continued Stay: Outpatient Treatment 1. Must meet ALL A The member and family/guardian have participated in the treatment plan development and discharge plan. B The member is making progress, but has not yet achieved the goals in the individualized treatment plan OR, if not making progress, has the capacity to resolve his or her problems OR new problems have been identified that are appropriately managed at the present level of care. C Continues to meet admission and medical necessity criteria Discharge: Outpatient Treatment 1. Must meet ONE A Continued stay guidelines are no longer met. B Appropriate and timely treatment is available at a less restrictive level of care. Page 4 of 18

5 SUBSTANCE ABUSE INTENSIVE OUTPATIENT TREATMENT Intensive Outpatient treatment for chemical dependency is a structured program run by professional staff trained in the treatment of chemical dependency. This level of care may or may not be facility based. The treatment is characterized primarily by a group approach, which has didactic and process components. Critical is the component of relapse prevention with specific adaptations for the individual. Teaching the disease concept of addiction, relapse prevention, addressing family issues with involvement of family or significant others in treatment, anger management, and social issues should be included. Treatment goals should focus on present identified behaviors and include the goal of abstinence with ongoing emphasis on attendance at community-based self-help. This level of care is to be considered as a first treatment option for members with support systems or use of a sober living environment and absence of significant physical and psychiatric complications. Frequency of attendance should be continually adjusted based on severity of signs and symptoms. IOP programs must meet a minimum of 3 hours per day/night for usually 3 days per week but can occur up to 7 days a week. Frequency and length of IOP programs should be determined by the member s presenting clinical condition, treatment history, current motivation for treatment, and support system. Medical monitoring may be indicated for this member s optimum well-being, but should not be a determining factor in member s participation in the program and can be obtained outside of the program s services. For children and adolescents, there is an expectation of face-to-face family meetings and involvement in treatment unless the physician determines this is contra-indicated. Page 5 of 18

6 Admission: Intensive Outpatient Treatment 1. Must be met Must meet medical necessity 2. Must meet ALL A The member is not demonstrating any life-threatening withdrawal symptoms that require acute inpatient detoxification. B The member is not suffering medical/psychiatric complications of his/her substance abuse that would inhibit ability to actively participate in and benefit from participation in the treatment. C The member is unable to maintain abstinence without a structured treatment intervention during a portion of the day. D The member s support system in supportive of recovery. If the member is without a support system the member has the ability to become involved in a self-help system. E The member suffers from significant impairment in social, medical, family and/or work functioning secondary to substance abuse. F The member demonstrates an interest in working toward the goal of rehabilitation. Continued Stay: Intensive Outpatient Treatment 1. Must be met Continues to meet admission and medical necessity criteria 2. Must meet ALL A The member and family/guardian have participated in the treatment plan development and discharge plan. B The member is making progress, but has not yet achieved the goals in the individualized treatment plan OR, if not making progress, has the capacity to resolve his or her problems OR new problems have been identified that are appropriately managed at the present level of care. C The member has been able to become abstinent but has been unable to address social, family, and/or work related tasks leading to structure. Discharge: Intensive Outpatient Treatment 1. Must meet ONE A Continued stay guidelines are no longer met. B Appropriate and timely treatment is available at a less restrictive level of care. AMBULATORY DRUG AND ALCOHOL DETOXIFICATION Page 6 of 18

7 The member should be accessed daily by a medical professional regarding vital signs, physical and behavioral symptoms. There should be 24-hour access to a physician should unexpected symptoms or worsening of symptoms occur. This level of care should be considered when the member has been medically assessed, and it is determined that the member does not require around-the-clock nursing care. Members entering this level of care should have support systems capable of accessing emergency services, and available if necessary to give medication. Admission: Ambulatory Drug and Alcohol Detoxification 1. Must be met Must meet medical necessity 2. & A or B must be met (For A to apply subset 1 or 2 must be checked) A The member is at risk for a severe withdrawal syndrome evidenced by a set of 1. symptoms clearly indicating an acute withdrawal process; Evidence of Alcohol and / or sedative-hypnotic withdrawal as manifested by the following: Anxiety, agitation, auditory disturbances, clouding of sensorium, delirium, diaphoresis, diarrhea, elevated vital signs (BP, temperature, pulse), headache, nausea and vomiting, seizures, tactile disturbances, tremor, visual disturbances (hallucinations). & In addition to the evidence of Alcohol, Sedative-hypnotic and/or Opiate withdrawal; the presenting signs/symptoms must cause: Clinically significant distress or impairment of social, occupational, or other important areas of functioning and Require active medical/behavioral treatment that can only be provided by daily A 2 monitoring with 24 hour access to a physician should symptoms worsen. The member is at risk for a severe withdrawal syndrome evidenced by a set of symptoms clearly indicating an acute withdrawal process; Evidence or Opiate withdrawal as manifested by the following: Abdominal cramps, agitation and anxiety, anorexia, arthralgias, diaphoresis, diarrhea, dilated pupils, elevated vital signs (BP, temp, pulse), irritability insomnia, lacrimation, muscle spasms, myalgias, piloerection, rhinorrhea, tachypnea, yawning. & In addition to the evidence of Alcohol, Sedative-hypnotic and/or Opiate withdrawal; the presenting signs/symptoms must cause: Clinically significant distress or impairment of social, occupational, or other important areas of functioning and Require active medical/behavioral treatment that can only be provided by daily Page 7 of 18

8 B monitoring with 24 hour access to a physician should symptoms worsen. The member exhibits behavioral conditions complicating the member s successful detoxification at a less restrictive level of care as evidenced by at least on of the following: 1. Major depression with severe vegetative symptoms and thought process impairment such that the member could not safely participate in a less restrictive level of care. Thought process impairment or abstract thinking impairment, to such a degree as to limit the member s ability to perform activities of daily living. Continued Stay: Ambulatory Drug and Alcohol Detoxification 1. Must meet BOTH A The member continues to suffer from withdrawal symptoms that require daily medical monitoring and intervention. B The treatment plan implemented for the member has not led to enough improvement in the member s condition such that the member could safely move to a less restrictive level of care and sustain improvement at that level. Discharge: Ambulatory Drug and Alcohol Detoxification 1. Must be met A Continued stay guidelines are no longer met. Page 8 of 18

9 SUBSTANCE ABUSE PARTIAL HOSPITALIZATION Provides a structured, coordinated, intense, comprehensive, multi-modal treatment for members who have access to a sober living environment. This approach includes teaching the disease concept of addiction, relapse prevention, family issues with involvement when appropriate, anger management and social issues teaching the member to develop structure within their own lives. Additionally, emphasis is placed on community self-help groups and relapse prevention. This level of care is not to be considered the first option for members with substance abuse issues but may be used as a safe alternative to inpatient treatment, however, should not be considered as an alternative to less restrictive treatment unless the member has a documented history of failure in Intensive Outpatient in the previous 6 months of treatment This level of care may also be appropriate for members who have lost their usual structured daily activities due to substance abuse, or due to co-morbid illness and lack coping skills to compensate. For these members, this level of care would be considered a focused program of transition that would stabilize the member and link him/her to community based resources and/or outpatient services. It has been determined that without the medical monitoring and direct access intervention for medical needs, the member would be too unstable to achieve optimum outcomes for and in his/her recovery process Medical monitoring is an identified need for members in this level of care and is indicated for the presenting primary diagnosis or a complicated dual presentation. By program design, medical monitoring and intervention is provided as part of the program. Though in certain situations, this level of care can exist separate from hospital based services, as a rule it is linked to a medical treatment facility. Partial hospitalization programs are run a minimum of 6 hours per day and are available a minimum of 5 days a week. Family treatment is indicated where the member may by living with family or significant others who are impacted by a member s substance use and/or are non-supportive of recovery but who are not actively opposed or sabotaging the rehabilitation goals For children and adolescents face-to-face meetings are a critical part of the treatment plan with frequency determined from clinical presentation but no less than once a week.. Multifamily groups are considered in addition to scheduled family therapy for the individual member and his/her family. Multifamily groups do not take the place of scheduled face-to-face family sessions. Page 9 of 18

10 Admission: Partial Hospitalization 1. Must be met Must meet medical necessity 2. Must Meet ALL A The member is not demonstrating and life-threatening withdrawal symptoms that require acute inpatient B The member is not suffering medical/ psychiatric complications that would prevent participation in the treatment provided. C The member has suffered such impairment with social, family, and/or work secondary to the substance abuse leading to inability to participate in routine daily activities had do not have coping skills to compensate. D The member is unable to maintain abstinence without structured treatment intervention during the day. E The member demonstrates an interest in working toward the goal of rehabilitation. Continued Stay: Partial Hospitalization 1. Must be met 2. Must meet ALL: A The member has participated in the development of the treatment plan and discharge plan. B The member has been able to become abstinent but has been unable to address social, family, and/or work related tasks leading to structure. C The treatment plan has not led to enough improvement to enable the member to be treated at a less restrictive level of care and sustain improvement. Discharge: Partial Hospitalization 1. Must Meet ONE A Continued stay guidelines are no longer met B Appropriate and timely treatment is available at a less restrictive level of care. Page 10 of 18

11 ACUTE INPATIENT DRUG AND ALCOHOL - DETOXIFICATION HOSPITALIZATION In-patient settings provide around-the-clock intensive, psychiatric medical and nursing care, continuous observation, and control of behavior as needed to ensure safety to members and others, as well as comprehensive multi-modal therapy for member and member support system. This level of care should not be considered until after the member has been evaluated medically. This level of care is not justified by simple intoxication or fear of relapse. For children and adolescents face-to-face meetings are a critical part of the treatment plan with frequency determined from clinical presentation but no less than once a week. (multi-family therapy does not take the place of individual family therapy). Initial Inpatient (Drug & Alcohol) DETOX Authorization 1. Must be met All components of Medical Necessity must be met 2. Must meet at least ONE: A OR B OR C (For A to apply subset 1 or 2 must be checked) A The member is at risk for a severe withdrawal syndrome evidenced by a set of symptoms 1 clearly indicating an acute withdrawal process; Evidence of Alcohol and / or sedativehypnotic withdrawal as manifested by the following: Anxiety, agitation, auditory disturbances, clouding of sensorial, delirium, diaphoresis, diarrhea, elevated vital signs (BP, temperature, pulse), headache, nausea and vomiting, seizures, tactile disturbances, tremor, visual disturbances (hallucinations). & In addition to the evidence of Alcohol, Sedative-hypnotic and/or Opiate withdrawal; the presenting signs/symptoms must cause: Clinically significant distress or impairment of social, occupational, or other important areas of functioning and Require active treatment that can only be provided by around the clock nursing A 2 care and medical intervention on a daily basis. The member is at risk for a severe withdrawal syndrome evidenced by a set of symptoms clearly indicating an acute withdrawal process; Evidence or Opiate withdrawal as manifested by the following: Abdominal cramps, agitation and anxiety, anorexia, arthralgias, diaphoresis, diarrhea, dilated pupils, elevated vital signs (BP, temp, pulse), irritability insomnia, lacrimation, muscle spasms, myalgias, piloerection, rhimorrhea, tachypnea, yawning. Page 11 of 18

12 B C & In addition to the evidence of Alcohol, Sedative-hypnotic and/or Opiate withdrawal; the presenting signs/symptoms must cause: Clinically significant distress or impairment of social, occupational, or other important areas of functioning and Require active treatment that can only be provided by around the clock nursing care and medical intervention on a daily basis. History of prior complicated and potentially life-threatening withdrawal such as seizures, delirium tremens or acute psychotic symptoms. The member has medical complications that, in combination with substance abuse, present a life-threatening health risk. A medical consultation is necessary to determine whether a medical admission is indicated for such a member. 3. Must meet at least ONE A The member exhibits behavioral conditions complicating the members successful detoxification at a less restrictive level of care evidenced by: Major depression with severe vegetative symptoms and thought process impairment such that the member could not safely participate in a less restrictive level of care. B The member exhibits behavioral conditions complicating the members successful detoxification at a less restrictive level of care evidenced by: Thought process impairment or abstract thinking impairment, to such a degree as to limit the member s ability to perform basic activities of daily living. Continued Stay, Inpatient Drug / Alcohol DETOX 1. Must meet ONE A The member continues to suffer from withdrawal symptoms that require active treatment efforts that can only be provided by around the clock intensive nursing care and documentation of daily physician contact with the member. B The member has developed a serious adverse reaction to medication requiring around the clock medical intervention that cannot be provided at a less restrictive level of care C The member s co-morbid medical or behavioral illness requires active treatment that can only be provided by around the clock nursing care and medical intervention on a daily basis 2. & Must Meet The treatment plan implemented for the member has not led to improvement in the member s condition to allow the member to safely move to a less restrictive level of the care and sustain improvement at that level. Page 12 of 18

13 Discharge Guidelines, Inpatient Drug /Alcohol DETOX 1. Must meet ONE A Continued stay guidelines are no longer met. B Appropriate and timely treatment is available at a less restrictive level of care. Page 13 of 18

14 SCHOOL-BASED TREATMENT School-based treatment is designed to identify mental health and substance abuse issues in children and adolescents and/or assist parents, teachers, and counselors in the treatment of a child or adolescent as outlined in an established formal educational/behavioral care treatment plan within a school setting. When a member has demonstrated an inability to attend treatment as prescribed. 1. School-Base Services must be justified as part of an overall formal educational/behavioral care treatment plan. For all requested services there must be an integrated treatment plan with clear goals and discharge criteria. 2. For School Based Services, group therapy is only adjunctive to individual and family therapy. In general, CompCare endorses individual and family interventions that focus on problem resolution rather than open-ended, process groups. 3. In addition, CompCare recognizes that unless there are issues of addiction or the member is at risk for hospitalization, any request for more than once a week treatment must be justified by the exact nature of the problem that is looking to be resolved and what the discharge criteria would be for that multisession intervention. 4. OP treatment for learning disabilities is generally not a covered benefit for OP therapy. Other Considerations 1. For School based programs, teacher referrals for (daily/episodic) behavior control are not considered in and of themselves a rationale for OP treatment. 2. CompCare does not pay for telephonic sessions, family or otherwise. 3. CompCare does not pay for case conferences nor does CompCare consider Case Conferences family therapy. School-based services are to be utilized under the following scenarios: a. When a member and/or their family have demonstrated an inability to attend treatment as prescribed. b. When a member and/ or their family has a life situation that makes treatment attendance very difficult and the process of getting to the appointments is a barrier to effective treatment. c. When a member has demonstrated an inability to successfully move from one level of care to another. d. When a member and/or their family requires a treatment boost in between office appointments to solidify treatment compliance and gains. e. When, in spite of active participation in another level of care, the extent to which issues in the home environment cannot be fully understood or resolved without direct intervention in that environment. Page 14 of 18

15 Initial Authorization - School-based treatment 1. Must meet A & B, C & D as applicable A All components of Medical Necessity must be met B There must be an integrated treatment plan with clear goals and discharge criteria. Services must be justified as part of an overall formal educational/behavioral care treatment plan. C For issues of addiction, 12 step program is part of the treatment plan. 2. & Must meet ONE A Member/Family report or express a subjective level of distress as it relates to behaviors and school performance. B Members symptoms must have resulted in a significant impairment of functioning in the home or school environment but these symptoms do not manifest themselves at a level that would call for a higher-level intervention. & Must meet C, D, E & as applicable F C Intervention is geared toward helping the family obtain resources and/or treatment options for the child in the community. D The treatment plan meets the needs of the child as is available. E Family involvement is face-to-face or there is a clear plan as to how to compensate for the lack of family availability in the treatment when the clinician is confronted with their absence. F For medication non-compliance, the treatment focuses on working with the child and family to improve the compliance with the medication component of the treatment plan. Continued Stay, School-based treatment 1. Must meet ONE A The treatment plan has not led to enough improvement in the child or adolescent s condition to allow the member to safely use community resources or a social support system to sustain improvement; or B The child or adolescent has developed new symptoms or the functioning has become so impaired so that the new diagnosis and treatment plan is indicated. Page 15 of 18

16 Discharge Guidelines, School-based treatment 1. Must meet ONE A Continued stay guidelines are no longer met. The problems noted on the treatment plan have been resolved sufficiently. B The child/adolescent or parent/caregiver is uncooperative or non-compliant with treatment and the absence of treatment poses no imminent risk of harm to child/adolescent or others. C After six (6) months of no improvement to any OP intervention, history and effectiveness of care show evidence that additional therapy will not create change or relief of symptoms (and family therapy has proved to be ineffective). Page 16 of 18

17 INPATIENT SUBSTANCE ABUSE REHABILITATION/ RESIDENTIAL TREATMENT Residential care is to be considered when a treatment milieu is considered necessary for a member to develop more adaptive coping mechanisms and facilitate a life style change in areas involving substance abuse. that can neither be addressed at a lower level of care nor require an inpatient intervention. The facility must have the capability to provide, as needed, medical and psychiatric monitoring of underlying physical and/or psychiatric illnesses and medical assessment and monitoring of withdrawal syndromes to ensure member safety. The treatment plan should address relapse prevention with individual adaptations. Prior to admission, less restrictive levels of care should be considered and attempted. This level of care is expected to stabilize the member is preparation for transition to a less restrictive level of care with a goal of reintegration into the community and is not to be considered solely for convenience or as an alternative to incarceration. For children and adolescents face-to-face meetings are a critical part of the treatment plan with frequency determined from clinical presentation but no less than once a week. (multi-family therapy does not take the place of individual family therapy). Page 17 of 18

18 Admission: Inpatient Rehabilitation/ Residential Treatment 1. Must be met Must meet medical necessity 2. Must meet ALL A The member is medically stable so that withdrawal symptoms, if present are not life threatening and can be safely monitored at this level of care. Member is not experiencing medical complications that prevent active participation and member is cognitively able to actively participate and benefit from treatment. B The member demonstrates an interest in working toward rehabilitation C The member has been unsuccessful in achieving abstinence for 6 months or more with active participation in IOP rehabilitation in the past 12 months. OR The member has failed to follow through with IOP Rehabilitation, including partial hospitalization, after 2 or more inpatient detoxifications. 3. & Must meet ONE A The member suffers form a co-morbid psychiatric illness or has bizarre thinking or psychomotor agitation/retardation that prevents participation at a less restrictive level of care. B The members living environment jeopardizes ability to achieve abstinence i.e.; family opposition to treatment or family actively involved in own substance abuse or severity dysfunctional living situation. C The member s social, family, occupational functioning is severely impaired secondary to substance abuse where much of the daily activity is focussed on obtaining, using or recuperating from substance abuse. Continued Stay: Inpatient Rehabilitation/ Residential Treatment 1. Must Meet Both A The member has participated in the development of the treatment plan including the discharge plan but continues to suffer from problems that caused the admission or additional problems have emerged. B The treatment plan has not led to enough improvement to allow member to move to a less restrictive level of care and sustain improvement. Discharge: Inpatient Rehabilitation/ Residential Treatment 1.Must meet ONE A Continued stay guidelines no longer met B Appropriate and timely treatment is available at a less restrictive level of care. Page 18 of 18

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