CLINICAL MEDICAL POLICY
|
|
- Leona Carmella Francis
- 5 years ago
- Views:
Transcription
1 Policy Name: Policy Number: Responsible Department(s): CLINICAL MEDICAL POLICY Vivitrol (Extended-release injectable naltrexone) MP-072-MD-DE Provider Notice Date: 04/15/2018 Issue Date: 05/15/2018 Effective Date: 05/15/2018 Annual Approval Date: 03/13/2019 Revision Date: Products: Application: Medical Management; Clinical Pharmacy N/A Page Number(s): 1 of 6 Highmark Health Options Medicaid All participating hospitals and providers DISCLAIMER Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions. POLICY STATEMENT Highmark Health Options may provide coverage under the medical or pharmacy benefits of the Company s Medicaid products for medically necessary injectable naltrexone (e.g., Vivitrol). This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records. The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations. DEFINITIONS Behavioral Health Providers Providers identified in one of the following specialties: Psychiatry, Neuropsychiatry, Addiction Medicine, Behavioral Health, Eating Disorder, Substance Abuse. Policy No. MP-072-MD-DE Page 1 of 6
2 PROCEDURES 1. Vivitrol (injectable naltrexone) is considered medically necessary for the initial treatment of opioid and/or alcohol dependence when the following criteria are met: A. The patient has a documented diagnosis of opioid and/or alcohol dependence; AND B. The patient is 18 years of age or older; AND C. Prescriber must be a Behavioral Health Provider or In-Network/Participating Provider; AND D. The dosing schedule is 380 mg IM every 4 weeks (within FDA-approved dosing guidelines); AND E. There is documentation that the patient has been evaluated for any other mental health condition and, if diagnosed, the patient is receiving treatment (counseling, medication, etc.) for it; AND F. Certain criteria must be met based upon the patient s diagnosis: 1) Alcohol dependence a. The patient is not actively consuming alcohol at the time of therapy initiation; AND b. The patient is not currently on opioid analgesics (e.g., for pain management), physiologically dependent on opioids, or in acute opioid withdrawal; AND c. An attestation is provided indicating the patient has been opioid-free for a minimum of 7-10 days prior to therapy initiation including having pertinent laboratory testing (e.g., a recent urine drug screen for opioids, naloxone challenge test) done; AND 2) Opioid dependence a. The patient is not currently on opioid analgesics (e.g., for pain management), physiologically dependent on opioids, or in acute opioid withdrawal; AND b. An attestation is provided indicating the patient has been opioid-free for a minimum of 7-10 days prior to therapy initiation including having pertinent laboratory testing (e.g., a recent urine drug screen for opioids, naloxone challenge test) done; AND G. Documentation is provided demonstrating tolerability to oral naltrexone; AND H. The provider attests to the patient being evaluated by a behavioral health provider or a provider licensed for drug and alcohol services (D&A provider), or that the patient has been referred to or has an appointment scheduled with that provider, for the purposes of determining a treatment plan 2. Vivitrol (injectable naltrexone) is considered medically necessary for the reauthorization of treatment of opioid and/or alcohol dependence when the following criteria are met: A. The patient has been consistently receiving injectable naltrexone, as verified by pharmacy claims, and if the patient has not refilled the medication in the last 45 days, the initial criteria will apply 3. Contraindications Vivitrol (injectable naltrexone) is contraindicated in: Patients receiving opioid analgesics Patients with current physiologic opioid dependence Policy No. MP-072-MD-DE Page 2 of 6
3 Patients in acute opioid withdrawal Any individual who has failed the naloxone challenge test or has a positive urine screen for opioids Patients who have previously exhibited hypersensitivity to naltrexone, polylactide-coglycolide (PLG), carboxymethylcellulose, or any other components of the diluent In acute hepatitis or liver failure, and its use in patients with active liver disease must be carefully considered in light of its hepatotoxic effects. 4. When the naltrexone (Vivitrol) injection services are not covered The administration of naltrexone is not covered for conditions other than those listed above because the scientific evidence has not been established. Coverage may be provided for any non-fda labeled indication or a medically accepted indication that is supported by nationally recognized pharmacy compendia or peer-reviewed medical literature for treatment of the diagnosis (es) for which it is prescribed and will be reviewed on a case-by-case basis to determine medical necessity. When non-formulary prior authorization criteria are not met, the request will be forwarded to a Medical Director for review. The physician reviewer must override criteria when, in their professional judgement, the requested medication is medically necessary. 5. Post-payment Audit Statement The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by Highmark Health Options at any time pursuant to the terms of your provider agreement. 6. Place of Service The place of service for the administration of naltrexone (Vivitrol) is inpatient and/or outpatient. GOVERNING BODIES APPROVAL The FDA approved an injectable (intramuscular), long-acting form of naltrexone (Vivitrol ) in April In October 2010, the FDA expanded the indication of Vivitrol to include the prevention of relapse to opioid dependence, following opioid detoxification. CODING REQUIREMENTS Covered Procedure Codes CPT Codes Description J2315 Injection, naltrexone, depot form, 1 mg [Vivitrol ] Covered Diagnosis Codes ICD-10 Codes Description F10.10 Alcohol abuse, uncomplicated F10.11 Alcohol abuse, in remission F Alcohol abuse with intoxication, uncomplicated Policy No. MP-072-MD-DE Page 3 of 6
4 F Alcohol abuse with intoxication delirium F Alcohol abuse with intoxication, uncomplicated F10.14 Alcohol abuse with alcohol-induced mood disorder F Alcohol abuse with alcohol-induced psychotic disorder with delusions F Alcohol abuse with alcohol-induced psychotic disorder with hallucinations F Alcohol abuse with alcohol-induced psychotic disorder, unspecified F Alcohol abuse with alcohol-induced anxiety disorder F Alcohol abuse with alcohol-induced sexual dysfunction F Alcohol abuse with alcohol-induced sleep disorder F Alcohol abuse with other alcohol-induced disorder F10.19 Alcohol abuse with unspecified alcohol-induced disorder F10.20 Alcohol dependence, uncomplicated F10.21 Alcohol dependence, in remission F Alcohol dependence with intoxication, uncomplicated F Alcohol dependence with intoxication delirium F Alcohol dependence with intoxication, unspecified F Alcohol dependence with withdrawal uncomplicated F Alcohol dependence with withdrawal delirium F Alcohol dependence with withdrawal with perceptual disturbance F Alcohol dependence with withdrawal, unspecified F10.24 Alcohol dependence with alcohol-induced mood disorder F Alcohol dependence with alcohol-induced psychotic disorder with delusions F Alcohol dependence with alcohol-induced psychotic disorder with hallucinations F Alcohol dependence with alcohol-induced psychotic disorder, unspecified F10.26 Alcohol dependence with alcohol-induced persisting amnestic disorder F10.27 Alcohol dependence with alcohol-induced persisting dementia F Alcohol dependence with alcohol-induced anxiety disorder F Alcohol dependence with alcohol-induced sexual dysfunction F Alcohol dependence with alcohol-induced sleep disorder F Alcohol dependence with other alcohol-induced disorder F10.29 Alcohol dependence with unspecified alcohol-induced disorder F Alcohol use, unspecified with intoxication, uncomplicated F Alcohol use, unspecified with intoxication, delirium F Alcohol use, unspecified with intoxication, unspecified F10.94 Alcohol use, unspecified with alcohol-induced mood disorder F Alcohol use, unspecified with alcohol-induced psychotic disorder with delusions F Alcohol use, unspecified with alcohol-induced psychotic disorder with hallucinations F Alcohol use, unspecified with alcohol-induced psychotic disorder, unspecified F10.96 Alcohol use, unspecified with alcohol-induced persisting amnestic disorder F10.97 Alcohol use, unspecified with alcohol-induced persisting dementia F Alcohol use, unspecified with alcohol-induced anxiety disorder F Alcohol use, unspecified with alcohol-induced sexual dysfunction F Alcohol use, unspecified with alcohol-induced sleep disorder Policy No. MP-072-MD-DE Page 4 of 6
5 F Alcohol use, unspecified with other alcohol-induced disorder F10.99 Alcohol use, unspecified with unspecified alcohol-induced disorder F11.10 Opioid abuse, uncomplicated F11.11 Opioid abuse, in remission F Opioid abuse with intoxication, uncomplicated F Opioid abuse with intoxication delirium F Opioid abuse with intoxication with perceptual disturbance F Opioid abuse with intoxication, unspecified F11.14 Opioid abuse with opioid-induced mood disorder F Opioid abuse with opioid-induced psychotic disorder with delusions F Opioid abuse with opioid-induced psychotic disorder with hallucinations F Opioid abuse with opioid-induced psychotic disorder, unspecified F Opioid abuse with opioid-induced sexual dysfunction F Opioid abuse with opioid-induced sleep disorder F Opioid abuse with other opioid-induced disorder F11.19 Opioid abuse with unspecified opioid-induced disorder F11.20 Opioid dependence, uncomplicated F11.21 Opioid dependence, in remission F Opioid dependence with intoxication, uncomplicated F Opioid dependence with intoxication delirium F Opioid dependence with intoxication with perceptual disturbance F Opioid dependence with intoxication, unspecified F11.23 Opioid dependence with withdrawal F11.24 Opioid dependence with opioid-induced mood disorder F Opioid dependence with opioid-induced psychotic disorder with delusions F Opioid dependence with opioid-induced psychotic disorder with hallucinations F Opioid dependence with opioid-induced psychotic disorder, unspecified F Opioid dependence with opioid-induced sexual dysfunction F Opioid dependence with opioid-induced sleep disorder F Opioid dependence with other opioid-induced disorder F11.29 Opioid dependence with unspecified opioid-induced disorder F11.90 Opioid use, unspecified, uncomplicated F Opioid use, unspecified with intoxication, uncomplicated F Opioid use, unspecified with intoxication delirium F Opioid use, unspecified with intoxication with perceptual disturbance F Opioid use, unspecified with intoxication, unspecified F11.93 Opioid use, unspecified with withdrawal F11.94 Opioid use, unspecified with opioid-induced mood disorder F Opioid use, unspecified with opioid-induced psychotic disorder with delusions F Opioid use, unspecified with opioid-induced psychotic disorder with hallucinations F Opioid use, unspecified with opioid-induced psychotic disorder, unspecified F Opioid use, unspecified with opioid-induced sexual dysfunction F Opioid use, unspecified with opioid-induced sleep disorder F Opioid use, unspecified with opioid-induced with other opioid-induced disorder Policy No. MP-072-MD-DE Page 5 of 6
6 F11.99 Opioid use, unspecified with unspecified opioid-induced disorder Z71.41 Alcohol abuse counseling and surveillance of alcoholic Z71.51 Drug abuse counseling and surveillance of drug abuser REIMBURSEMENT Participating facilities will be reimbursed per their Highmark Health Options contract. POLICY SOURCE(S) The ASAM National Practice Guideline. Accessed online May 17, SAMHSA/CSAT Treatment Improvement Protocols. Accessed online May 17, 2017 and available at: Nicholas L, Bragaw L, Ruetsch C. Opioid Dependence Treatment and Guidelines. Accessed online May 17, 2017 available at: Vivitrol [package insert] Waltham, MA. Alkermes, December Policy History Date Activity 11/14/2017 Initial policy developed 03/13/2018 QI/UM Committee approval 05/15/2018 Provider effective date Policy No. MP-072-MD-DE Page 6 of 6
CLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Policy Name: Faslodex (fulvestrant) Policy Number: MP-044-MD-DE Responsible Department(s): Medical Management; Clinical Pharmacy Provider Notice Date: 10/01/2017 Original Effective
More informationClinical Policy: Naltrexone (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: 03.01.12 Last Review Date: 02.19 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of
More informationClinical Policy: Naltrexone (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Vivitrol) Reference Number: CP.PHAR.96 Effective Date: 03.01.12 Last Review Date: 02.18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of
More informationCLINICAL MEDICAL POLICY
Policy Name: Policy Number: Responsible Department(s): CLINICAL MEDICAL POLICY Tysabri (natalizumab) MP-042-MD-WV Provider Notice Date: 10/01/2017 Original Effective Date: 11/01/2017 Annual Approval Date:
More informationCLINICAL MEDICAL POLICY
Policy Name: Policy Number: Approved By: CLINICAL MEDICAL POLICY ADCETRIS (Brentuximab Vedotin) MP-035-MD-DE Provider Notice Date: 11/1/2016 Original Effective Date: 12/1/2016 Medical Management Annual
More informationCLINICAL MEDICATION POLICY
Policy Name: Policy Number: Approved By: CLINICAL MEDICATION POLICY Adcetris (brentuximab vedotin) MP-035-MD-DE Provider Notice Date: 08/01/2017 Original Effective Date: 09/01/2017 Annual Approval Date:
More informationCLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Policy Name: Avastin (bevacizumab) Policy Number: MP-030-MD-DE Responsible Department(s): Medical Management; Clinical Pharmacy Provider Notice Date: 10/01/2017 Original Effective
More informationCLINICAL MEDICAL POLICY
Policy Name: Policy Number: Approved By: Provider Notice Date: CLINICAL MEDICAL POLICY Portrazza (Necitumumab) MP-021-MD-WV Medical Management Original Effective Date: 06/02/2016 Annual Approval Date:
More informationCLINICAL MEDICATION POLICY
CLINICAL MEDICATION POLICY Policy Name: Opdivo (nivolumab) injection Policy Number: Approved By: Medical Management, Clinical Pharmacy Products: Highmark Health Options Application: All participating hospitals
More informationUNHEALTHY ALCOHOL USE SCREENING and FOLLOW-UP (ASF) HEDIS (Administrative)
UNHEALTHY ALCOHOL USE SCREENING and FOLLOW-UP (ASF) APPLICATIONS OBJECTIVE Purpose of Measure: ELIGIBLE POPULATION Which members are included? STANDARD OF CARE NCQA ACCEPTED CODES HEDIS (Administrative)
More informationCLINICAL MEDICATION POLICY
Policy Name: Policy Number: Approved By: CLINICAL MEDICATION POLICY Adcetris (Brentuximab Vedotin) MP-035-MD-WV Provider Notice Date: 07/03/2017 Original Effective Date: 08/03/2017 Annual Approval Date:
More informationPerformCare Provider Network Scott Daubert PhD, VP Provider Network & Account Management. AD ICD-10-CM Frequently Asked Questions
Provider Notice To: From: PerformCare Provider Network Scott Daubert PhD, VP Provider Network & Account Management Date: April 23, 2015 Subject: AD 15 105 ICD-10-CM Frequently Asked Questions The Centers
More informationBehavioral Health Services An essential, coding, billing and reimbursement resource for psychiatrists, psychologists, and clinical social workers
CODING & PAYMENT GUIDE 2019 Behavioral Health Services An essential, coding, billing and reimbursement resource for psychiatrists, psychologists, and clinical social workers Power up your coding optum360coding.com
More informationCLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Policy Name: Rituxan (rituximab) Policy Number: MP-031-MD-DE Responsible Department(s): Medical Management; Clinical Pharmacy Provider Notice Date: 10/01/2017 Issue Date: 11/01/2017
More informationSAMPLE. Behavioral Health Services
Coding and Payment Guide www.optumcoding.com Behavioral Health Services An essential coding, billing, and reimbursement resource for psychiatrists, psychologists, and clinical social workers 2017 a ICD-10
More informationINDIANA HEALTH COVERAGE PROGRAMS
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Division of Mental Health and Addiction (DMHA) Behavioral and Primary Healthcare Coordination (BPHC) Codes Note: Due to possible changes in Indiana
More informationSANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery
Page 1 of 9 SANTA BARBARA COUNTY DEPARTMENT OF Behavioral Wellness A System of Care and Recovery Departmental Polley and Procedure Section Sub-section Alcohol and Drug Program (ADP) Effective: 7/11/2018
More information9/9/2016. Drug Name (select from list of drugs shown) Bunavail Buccal Film (buprenorphinenaloxone) Suboxone Sublingual Film (buprenorphine-naloxone)
9/9/2016 Prior Authorization Form PASSPORT HEALTH PLAN KENTUCKY MEDICAID Buprenorphine Products This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information,
More informationPrescription Drug Monitoring and Toxicology ICD-10-CM. resource guide. Provided as a service of Quest Diagnostics. 1 ICD-10-CM Resource Guide
Prescription Drug Monitoring and Toxicology ICD-10-CM resource guide Provided as a service of Quest Diagnostics 1 ICD-10-CM Resource Guide Table of contents About ICD-10 3 Pain Management: Top Mappings
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Effective Date: 04.18 Last Review Date: 04.18 Line of Business: Medicaid- AHCCCS Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description
More informationToday s Presenter 4/22/2015. ICD-10-CM Documentation and Diagnosis: Behavioral Health. By Tammy Jones, CPC, COC
ICD-10-CM Documentation and Diagnosis: Behavioral Health By Tammy Jones, CPC, COC Today s Presenter Tammy Jones, CPC, COC SVA Healthcare Services, LLC 608.826.2147 jonest@sva.com 1 ICD-10 Documentation
More informationINDIANA HEALTH COVERAGE PROGRAMS
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Medicaid Rehabilitation Option (MRO) Services Codes Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding
More informationCLINICAL MEDICAL POLICY
Policy Name: Policy Number: Responsible Department(s): CLINICAL MEDICAL POLICY Single-use Ambulatory Electrocardiographic Monitors (e.g., Zio Patch) MP-076-MD-DE Medical Management Provider Notice Date:
More informationAddiction and Recovery Treatment Services (ARTS) Reimbursement Structure
Page 1 of 13 Billing Code Service Name Service Description ASAM Level APPROVED CODES & RATES APPROVED BY CENTERS FOR MEDICARE AND MEDICAID SERVICES AUGUST 25, 2017 Community Based Care Unit Lengths Annual
More informationSpecifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine s Standards of Care
ORIGINAL RESEARCH Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine s Standards of Care Alex H.S. Harris, PhD, MS, Constance M. Weisner, DPh, MSW, Mady Chalk,
More informationKurt Haspert, MS, CRNP University of Maryland Baltimore Washington Medical Center
Kurt Haspert, MS, CRNP University of Maryland Baltimore Washington Medical Center Data from the National Vital Statistics System Mortality The age-adjusted rate of drug overdose deaths in the United States
More informationCLINICAL POLICY Clinical Policy: Extended Release Opioid Analgesics
Reference Number: AZ.CP.PMN.97 Effective Date: 02.11 Last Review Date: 02.18 Line of Business: Medicaid- AHCCCS Revision Log See Important Reminder at the end of this policy for important regulatory and
More informationCLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Policy Name: Xolair (omalizumab) Policy Number: MP-051-MD-DE Responsible Department(s): Medical Management; Clinical Pharmacy Provider Notice Date: 10/01/2017 Original Effective
More informationTuscarawas County Health Department. Vivitrol Treatment Consent
Tuscarawas County Health Department Vivitrol Treatment Consent I. Vivitrol Medication Guide: a. VIVITROL (viv-i-trol) (naltrexone for extended-release injectable suspension) b. Read this Medication Guide
More informationICD-10-CM Resource Guide
Prescription Drug Monitoring and Toxicology ICD-10-CM Resource Guide Provided as a service of Quest Diagnostics 1 ICD-10-CM Resource Guide Table of Contents About ICD-10 3 Pain Management: Top Mappings
More informationUpdated: 08/2017 DMMA Approved: 11/2017
Request for Prior Authorization for Therapy to Treat Binge Eating Disorder Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for medications to treat Binge
More informationClinical Policy: Buprenorphine-Naloxone (Bunavail, Suboxone, Zubsolv) Reference Number: CP.PMN.81 Effective Date: Last Review Date: 02.
Clinical Policy: (Bunavail, Suboxone, Zubsolv) Reference Number: CP.PMN.81 Effective Date: 09.01.17 Last Review Date: 02.18 Line of Business: Medicaid See Important Reminder at the end of this policy for
More informationCALIFORNIA COUNTIES TREATMENT RECORD REQUIREMENTS
CALIFORNIA COUNTIES TREATMENT RECORD REQUIREMENTS Every service provided is subject to Beacon Health Options, State of California and federal audits. All treatment records must include documentation of
More informationClinical Guidelines and Coverage Limitations for Medication Assisted Treatment (MAT)
Clinical Guidelines and Coverage Limitations for Medication Assisted Treatment (MAT) For Apple Health clients served Fee-for-Service and through contracted Medicaid Managed Care Organizations Updated January
More informationMedication for the Treatment of Alcohol Use Disorder. Pocket Guide
Medication for the Treatment of Alcohol Use Disorder Pocket Guide Medications are underused in the treatment of alcohol use disorder. According to the National Survey on Drug Use and Health, of the estimated
More informationClinical Policy: Lofexidine (Lucemyra) Reference Number: ERX.NPA.88 Effective Date:
Clinical Policy: (Lucemyra) Reference Number: ERX.NPA.88 Effective Date: 07.31.18 Last Review Date: 08.18 Revision Log See Important Reminder at the end of this policy for important regulatory and legal
More informationSubstance Use Disorders
Substance Use Disorders Substance Use Disorder This is a 15 minute webinar session for CNC physicians and staff CNC holds webinars monthly to address topics related to risk adjustment documentation and
More informationClinical Policy: Buprenorphine-Naloxone (Suboxone, Bunavail, Zubsolv) Reference Number: CP.PMN.XX. Line of Business: Medicaid
Clinical Policy: (Suboxone, Bunavail, Zubsolv) Reference Number: CP.PMN.XX Effective Date: 09/17 Last Review Date: 08/17 Line of Business: Medicaid See Important Reminder at the end of this policy for
More informationService Review Criteria
Pre-Review Review for HUM 26: immediate health/safety concerns. If MET, refer to medical staff and outreach phone call to Provider. Please note concerns here and in the Clinical Justification: Review for
More informationState Targeted Opioid Response Initiative (STORI) Fee-for-Service (FFS) Open Enrollment
State Targeted Opioid Response Initiative (STORI) Fee-for-Service (FFS) Open Enrollment DEPARTMENT OF HUMAN SERVICES (DHS) DIVISION OF MENTAL HEALTH & ADDICTION SERVICES (DMHAS) STORI INFORMATIONAL WEBINAR
More informationClinical Policy: Opioid Analgesics Reference Number: CP.PMN.97 Effective Date: Last Review Date: 02.19
Clinical Policy: Reference Number: CP.PMN.97 Effective Date: 02.11 Last Review Date: 02.19 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important regulatory
More informationFY17 SCOPE OF WORK TEMPLATE. Name of Program/Services: Medication-Assisted Treatment: Buprenorphine
FY17 SCOPE OF WORK TEMPLATE Name of Program/Services: Medication-Assisted Treatment: Buprenorphine Procedure Code: Modification of 99212, 99213 and 99214: 99212 22 99213 22 99214 22 Definitions: Buprenorphine
More informationClinical Policy: Opioid Analgesics Reference Number: CP.PMN.97 Effective Date: Last Review Date: 02.18
Clinical Policy: Reference Number: CP.PMN.97 Effective Date: 02.11 Last Review Date: 02.18 Line of Business: Medicaid Revision Log See Important Reminder at the end of this policy for important regulatory
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Reference Number: HIM.PA.139 Effective Date: 12.01.17 Last Review Date: 02.18 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the end of this policy
More informationSection I. Short-acting opioid Prior Authorization Criteria
Request for Prior Authorization for Opioid analgesics Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 Requests for opioid analgesics may be subject to prior authorization
More informationClinical Guidelines and Coverage Limitations for Medication Assisted Treatment (MAT)
Clinical Guidelines and Coverage Limitations for Medication Assisted Treatment (MAT) What has changed? Effective January 16, 2018, Coordinated Care will change the requirement for form HCA 13-333 Medication
More informationBehavioral Health Prior Authorization Form
Behavioral Health Prior Authorization Form Iowa Behavioral Health (BH) Utilization Management (UM) at 1-844-214-2469. Today s date: Date of admission/service start: Please note: Authorization is based
More informationNebraska Medicaid Criteria. Abilify Maintena
Nebraska Medicaid Criteria All initial and renewal authorizations are for 12 months in duration. Abilify Maintena *Criteria for Authorization for Abilify Maintena The individual has a current DSM diagnosis
More informationURINE DRUG TESTING FOR SUBSTANCE ABUSE TREATMENT AND CHRONIC PAIN MANAGEMENT
Status Active Medical and Behavioral Health Policy Section: Laboratory Policy Number: VI-47 Effective Date: 07/21/2014 Blue Cross and Blue Shield of Minnesota medical policies do not imply that members
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Lucemyra) Reference Number: CP.PMN.152 Effective Date: 07.31.18 Last Review Date: 08.18 Line of Business: Commercial, HIM, Medicaid Revision Log See Important Reminder at the end of this
More informationMedical Necessity Criteria
SECTION 3: MEDICAL NECESSITY CRITERIA 3.0 Definition of Medical Necessity Medical necessity is the principal criteria by which the Fresno County Mental Health Plan (FCMHP) decides to accept and approve
More informationSubstance Use Disorders (SUDs) and Medication Assisted Treatment (MAT) for Opiates
Substance Use Disorders (SUDs) and Medication Assisted Treatment (MAT) for Opiates What is MAT? Medication Assisted Treatment (MAT) is the use of medications, in addition to counseling, cognitive behavioral
More informationObjectives 1/25/18. An Update on Controlled Substance Prescribing Laws & Rules for CNMs. Exclusionary Formulary Effective: May 17, 2017
1/25/18 An Update on Controlled Substance Prescribing Laws & Rules for CNMs Keeley Harding, DNP, APRN, CPNP-AC/PC February 4, 2018 2018 Ohio ACNM Forward Kalahari Resorts and Conference Center, Sandusky,
More informationCLINICAL MEDICAL POLICY
Policy Name: Policy Number: Responsible Department(s): CLINICAL MEDICAL POLICY Molecular Markers for Fine Needle Aspirates of Thyroid Nodules MP-065-MD-DE Medical Management Provider Notice Date: 10/15/2018;
More informationVIVITROL (naltrexone for extended-release injectable suspension) A µ-opioid Receptor Antagonist
MECHANISM OF ACTION VIVITROL (naltrexone for extended-release injectable suspension) A µ-opioid Receptor Antagonist VIVITROL is indicated for prevention of relapse to opioid dependence, following opioid
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Opioid Analgesics Reference Number: HIM.PA.139 Effective Date: 12.01.17 Last Review Date: 11.17 Line of Business: Health Insurance Marketplace Revision Log See Important Reminder at the
More informationVIRGINIA MEDICAID ADDICTION AND RECOVERY TREATMENT SERVICES (ARTS) OFFICE BASED OPIOID PROVIDER (OBOT) PAYMENT MODEL 3 rd Annual Mental Health Summit
1 VIRGINIA MEDICAID ADDICTION AND RECOVERY TREATMENT SERVICES (ARTS) OFFICE BASED OPIOID PROVIDER (OBOT) PAYMENT MODEL 3 rd Annual Mental Health Summit May 9, 2017 Virginians Covered by Medicaid and CHIP
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: No Coverage Criteria/Off-Label Use Policy Reference Number: CP.PMN.53 Effective Date: 07.01.18 Last Review Date: 05.01.18 Line of Business: Oregon Health Plan Revision Log See Important
More informationCARD/MAIL/PRE-APPROVAL/PREFERRED RIDER FOR PRESCRIPTION DRUG [INSURANCE] [Policy]holder: Group Policy No: Effective Date:
RIDER FOR PRESCRIPTION DRUG [INSURANCE] [Policy]holder: Group Policy No: Effective Date: CARD/MAIL/PRE-APPROVAL/PREFERRED The Prescription Drug Coverage under this Rider [replaces] [supplements] the Prescription
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Reference Number: LA.PPA.12 Effective Date: 02/11 Last Review Date: 01/18 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the end of this policy for
More informationClinical Policy: Pasireotide (Signifor LAR) Reference Number: CP.PHAR.332 Effective Date: Last Review Date: Line of Business: Medicaid
Clinical Policy: (Signifor LAR) Reference Number: CP.PHAR.332 Effective Date: 03.01.17 Last Review Date: 11.17 Line of Business: Medicaid Coding Implications Revision Log See Important Reminder at the
More information2. Is this request for a preferred medication? Y N
Pharmacy Prior Authorization AETA BETTER HEALTH EW JERSE (MEDICAID) Opioids Long-Acting and Short-Acting (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review
More information2018 Billing and Coding Guide for
1 2018 Billing and Coding Guide for Table of Contents 1. Introduction 2. Coding Quick Reference Guide 3. Coding for Probuphine (buprenorphine) implant National Drug Codes (NDC) 1 Healthcare Common Procedure
More informationAcute General Medical and Surgical Admission:
Acute General Medical and Surgical Admission: Managing Substance Use Disorders in Patients Who are Severely Ill Scott Grantham, MD Executive Director, Behavioral Health Saint Francis Health System By the
More informationClinical Policy: Naloxone (Evzio) Reference Number: CP.PMN.139 Effective Date: Last Review Date: Line of Business: Commercial, Medicaid
Clinical Policy: Naloxone (Evzio) Reference Number: CP.PMN.139 Effective Date: 11.16.16 Last Review Date: 08.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the end of
More informationMEDICAL POLICY: Telehealth Services
POLICY: PG0142 ORIGINAL EFFECTIVE: 01/01/08 LAST REVIEW: 12/12/17 MEDICAL POLICY: Telehealth Services GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated
More informationCalcitonin Gene Related Peptide Receptor Inhibitors Prior Authorization Criteria:
Request for Prior Authorization for Calcitonin Gene Related Peptide Receptor Inhibitors Website Form www.highmarkhealthoptions.com Submit request via: Fax - 1-855-476-4158 All requests for Calcitonin Gene
More informationMedicaid and the Opioid Crisis
Medicaid and the Opioid Crisis Erica Floyd Thomas Bureau Chief of Medicaid Policy Agency for Health Care Administration Presented to: Medical Care Advisory Committee March 20, 2018 1 Florida Medicaid Covers
More informationTreatment Alternatives for Substance Use Disorders
Treatment Alternatives for Substance Use Disorders Dean Drosnes, MD, FASAM Associate Medical Director Director, Chronic Pain and SUD Program Caron Treatment Centers 1 Disclosure The speaker has no conflict
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Thyrogen) Reference Number: CP.PHAR.95 Effective Date: 03.12 Last Review Date: 08.18 Line of Business: Medicaid, HIM-Medical Benefit Revision Log See Important Reminder at the end of
More informationSHARED CARE GUIDELINE FOR THE MANAGEMENT OF PATIENTS ON NALTREXONE FOR OPIOID DEPENDENCE
SHARED CARE GUIDELINE FOR THE MANAGEMENT OF PATIENTS ON NALTREXONE FOR OPIOID DEPENDENCE INDICATION Naltrexone is a pure opiate antagonist licensed as an adjunctive prophylactic therapy in the maintenance
More informationUpdates and Clarifications to the Hospice Policy Chapter of the Benefit Policy Manual. Compliance for Hospice Providers Revised September 2014
Compliance Update National Hospice and Palliative Care Organization Regulatory & Compliance www.nhpco.org/regulatory Updates and Clarifications to the Hospice Policy Chapter of the Benefit Policy Manual
More informationPrepublication Requirements
Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: (Probuphine, Sublocade) Reference Number: CP.PHAR.289 Effective Date: 11.16.16 Last Review Date: 05.18 Line of Business: Commercial, Medicaid Revision Log See Important Reminder at the
More informationRECOMMENDATIONS FOR HEALTH CARE PROVIDERS
Ending Addiction Changes Everything RECOMMENDATIONS FOR HEALTH CARE PROVIDERS CRITICAL ADDICTION PREVENTION, TREATMENT AND MANAGEMENT SERVICES TO INCLUDE IN ROUTINE HEALTH CARE PRACTICE JULY 2013 In the
More informationReimbursement Information for Automated Breast Ultrasound Screening
GE Healthcare Reimbursement Information for Automated Breast Ultrasound Screening January 2015 www.gehealthcare.com/reimbursement The Invenia ABUS is indicated as an adjunct to mammography for breast cancer
More informationOPIOID USE DISORDER CENTERS OF EXCELLENCE APPLICATION GENERAL INFORMATION
OPIOID USE DISORDER CENTERS OF EXCELLENCE APPLICATION GENERAL INFORMATION The Department of Human Services (DHS) is implementing 50 opioid use disorder (OUD) Health Homes or Centers of Excellence (COE)
More informationProposed Revision to Med (i)
Proposed Revision to Med 501.02 (i) I. Purpose This rule has been adopted to enable the Board to best protect public health and safety while providing a framework for licensees to effectively treat and
More informationAn Alternative Payment Model Concept for Office-based Treatment of Opioid Use Disorder
An Alternative Payment Model Concept for Office-based Treatment of Opioid Use Disorder CONTENTS I. Need for an Alternative Payment Model for Opioid Use Disorder and Addiction... 2 A. Improving Services
More informationVivitrol Drug Court and Medication Assisted Treatment
Vivitrol Drug Court and Medication Assisted Treatment Amy Black, CNP and Judge Fred Moses Court program Self-starters Mission Statement To provide court-managed, medically assisted drug intervention treatment
More informationSHARED CARE GUIDELINE FOR THE MANAGEMENT OF PATIENTS ON NALTREXONE FOR ALCOHOL DEPENDENCE INDICATION
SHARED CARE GUIDELINE FOR THE MANAGEMENT OF PATIENTS ON NALTREXONE FOR ALCOHOL DEPENDENCE INDICATION Naltrexone is used as part of a comprehensive programme of treatment against alcoholism to reduce the
More informationFighting Today s Opioid Epidemic
Fighting Today s Opioid Epidemic Establish in 1966 as a Public Health Department Location: Rock Falls, IL/Whiteside County Population: Whiteside County 2015--57,079 Serving Rural IL: Primarily Whiteside,
More informationMEDICAL ASSISTANCE HANDBOOK PRIOR AUTHORIZATION OF PHARMACEUTICAL SERVICES
MEDICAL ASSISTANCE HBOOK I. Requirements for Prior Authorization of Analgesics, Narcotic Long Acting A. Prescriptions That Require Prior Authorization Prescriptions for Analgesics, Narcotic Long Acting
More informationKey Behavioral Health Measures (18 Years and Older)
At WellCare, we value everything you do to deliver quality care for our members your patients to make sure they have a positive health care experience. That s why we ve created this easy-to-use, informative
More informationReimbursement Information for Diagnostic Ultrasound and Ultrasound-guided Procedures Commonly Performed by Otolaryngologists
GE Healthcare Reimbursement Information for Diagnostic Ultrasound and Ultrasound-guided Procedures Commonly Performed by Otolaryngologists 1 January, 2013 www.gehealthcare.com/reimbursement imagination
More informationState of California Health and Human Services Agency Department of Health Care Services
State of California Health and Human Services Agency Department of Health Care Services JENNIFER KENT DIRECTOR EDMUND G. BROWN JR. GOVERNOR DATE: MHSUDS INFORMATION NOTICE NO.: 18-053 TO: SUBJECT: SUPERSEDES:
More informationArwen Podesta, MD. ABIHM, ABAM, Forensic Psychiatry
The State of Medicine in Addiction Recovery Arwen Podesta, MD ABIHM, ABAM, Forensic Psychiatry www.podestawellness.com 504-252-0026 http://www.addictionpolicy.org/ Overview Addiction is a serious, chronic
More informationMEDICARE LOCAL COVERAGE DETERMINATION COMMONLY USED DIAGNOSIS CODES
MEDICARE LOCAL COVERAGE DETERMINATION COMMONLY USED DIAGNOSIS CODES Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug
More informationSee Policy CPT CODE section below for any prior authorization requirements. This policy applies to:
Effective Date: 1/1/2019 Section: MED Policy No: 108 Medical Officer 1/1/19 Date Medical Policy Committee Approved Date: 6/12; 9/12; 7/13; 10/13; 12/13; 11/14; 1/15; 12/15; 4/16; 12/16; 7/17; 8/17; 12/17;
More informationRevenue Cycle Solutions Consulting & Management Services. Why Words Matter. Through a Psychiatry Lens The Advisory Board Company advisory.
Revenue Cycle Solutions Consulting & Management Services Why Words Matter Through a Psychiatry Lens 2014 The Advisory Board Company advisory.com Key Objectives for Today s Session 1. Develop understanding
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Transmucosal Immediate Release Fentanyl Products Reference Number: CP.CPA.211 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Commercial Revision Log See Important Reminder
More informationThe Role of Primary Care Teams and the Medical Neighborhood in Addressing the Opioid Crisis in Maine. March 10, 2016
The Role of Primary Care Teams and the Medical Neighborhood in Addressing the Opioid Crisis in Maine March 10, 2016 Objectives Review current state of opioid crisis in Maine Briefly review physiology of
More informationADMINISTRATIVE POLICY AND PROCEDURE
Page 1 of 5 SECTION: Medical SUBJECT: Neuropsychological and Psychological Testing DATE OF ORIGIN: 2/13/13 REVIEW DATES: 7/17/15 EFFECTIVE DATE: 12/15/16 APPROVED BY: EXECUTIVE DIRECTOR MEDICAL DIRECTOR
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Policy Reference Number: CP.PMN.53 Effective Date: 09.12.17 Last Review Date: 11.18 Line of Business: Medicaid, HIM-Medical Benefit Revision Log See Important Reminder at the end of this
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Clinical Policy: Transmucosal Immediate Release Fentanyl Products Reference Number: CP.HNMC.211 Effective Date: 11.16.16 Last Review Date: 11.17 Line of Business: Medicaid Medi-Cal Revision Log See Important
More informationFOLLOW-UP CARE FOR CHILDREN PRESCRIBED ADHD MEDICATION (ADD) To ensure child members who are newly prescribed attentiondeficit/hyperactivity
FOLLOW-UP CARE FOR CHILDREN PRESCRIBED ADHD MEDICATION (ADD) APPLICATIONS OBJECTIVE Purpose of Measure: ELIGIBLE POPULATION Which members are included? STANDARD OF CARE NCQA ACCEPTED CODES DOCUMENTATION
More informationBUPRENORPHINE/NALOXONE THERAPY DOM CLINICAL GUIDELINES AND RECOMMENDED CHANGES
BUPRENORPHINE/NALOXONE THERAPY DOM CLINICAL GUIDELINES AND RECOMMENDED CHANGES BACKGROUND In September 2012, the Division of Medicaid (DOM) implemented criteria through electronic prior authorization (PA)
More informationDISCLAIMER. Original Effective Date: 6/23/14. Subject: Vivitrol (naltrexone for extended-release injectable suspension) Policy Number: MCP-177
Subject: Vivitrol (naltrexone for extended-release injectable suspension) Policy Number: MCP-177 Original Effective Date: 6/23/14 Revision Date(s): Review Date(s): 12/16/15; 9/15/2016; 6/22/2017 DISCLAIMER
More informationNew Initiatives to Expand Access to Medication Assisted Treatment in NYS OASAS
New Initiatives to Expand Access to Medication Assisted Treatment in NYS OASAS Charles W. Morgan, MD, DFASAM, FAAFP Medical Director New York State Office of Alcoholism and Substance Abuse Services February
More informationSee Important Reminder at the end of this policy for important regulatory and legal information.
Policy: Atopic Dermatitis and Topical Antipsoriatics Reference Number: TCHP.PHAR.18004 Effective Date: 01.01.18 Last Review Date: 10.12.18 Line of Business: Oregon Health Plan Revision Log See Important
More information