Medication Assisted Treatment (MAT) (ARCHIVED)

Policy ID: Z-9007-03

Section: Miscellaneous

Effective Date: February 01, 2019

Revised Date: June 28, 2023

Revision Effective Date: September 04, 2023

Last Reviewed: July 06, 2023

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective September 04, 2023. Click the Archive tab above for more information.

Policy ID: Z-9007-02

Section: Miscellaneous

Effective Date: February 01, 2019

Revised Date: January 05, 2021

Revision Effective Date: March 01, 2021

Last Reviewed: January 26, 2023

Archived Date: September 03, 2023

Applies To: Commercial and Medicaid Expansion

Description

Medication Assisted Treatment (MAT) uses FDA approved pharmacological agents in combination with behavioral and psychosocial therapies to provide a comprehensive approach to the treatment of opioid use disorders. Medication Assisted Treatment for Opioid Dependence is limited to behavioral health and medical providers or programs that have the appropriate DEA certifications and meet all legally mandated requirements.

Criteria

Intensity of Service:
For Opioid Treatment Program (OTP)

Must meet all of the following:

Hold a current nonprovisional North Dakota license and maintains compliance with North Dakota Administrative Code 75.09.1-10. For out of state providers, appropriate state licensure in the state they are located and prescribe is required.
Complies with all expectations of the federal opioid treatment standards found in Title 42 of the Code of Federal Regulations Part 8 (42 CFR 8);
Has SAMHSA certification;
Is registered with the Drug Enforcement Administration (DEA), through a local DEA office;
Policies are in place for physicians who are waivered under The Drug Addiction Treatment Act of 2000 (DATA 2000), to assure compliance with the Controlled Substances ACT (CSWQ) 28 USC 802);
Regular review of prescription drug monitoring program (PDMP);
Staff have training and general competency in substance use disorder recognition and management of all aspects of treatment;
Staff have specific training and knowledge about working with individuals with Opioid Use Disorders, including specific expertise in the use of medication assisted treatment. All staff will work within scope of individual licensure;
Capacity to refer to mental health/ psychiatric services for evaluation and treatment of co-occurring mental illness, if needed.

For Office-based Opioid Treatment (OBOT)

Must meet all of the following:

Adheres to the Substance Abuse and Mental Health Services Administration (SAMHSA) regulations for addiction treatment under the provisions of the Drug Addiction Treatment Act of 2000 (DATA 2000);
Prescribers are registered with the Drug Enforcement Administration (DEA) to dispense controlled substances;
Provider maintains a log of all current individuals according to Drug Enforcement Administration guidelines;
Regular review of prescription drug monitoring program (PDMP);
Capacity to monitor adherence using medically necessary and appropriate drug screening and pill counts or both;
An individualized recovery plan including counseling and psychosocial supports is provided in addition to medication management;
Staff have training and general competency in substance use disorder recognition and management of all aspects of treatment;
Staff have specific training and knowledge about working with individuals with Opioid Use Disorders, including specific expertise in the use of medication assisted treatment (MAT). All staff will work within scope of individual licensure;
Knowledge of community substance use disorder providers, capacity to refer and arrange for substance use disorder services as needed;
Ongoing collaborative decision making between MAT providers and psychosocial treatment providers;
Capacity to refer to psychiatric services for evaluation of co-occurring mental illness, if needed.

Criteria for Initiation of Treatment

Must meet all the intensity of services for either OTP or OBOT.
All the following must be met:
1. The individual has a documented primary diagnosis of opioid dependence, per the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, which is the primary focus of active treatment.
2. Treatment type, frequency and duration is administered utilizing current evidence-based standards and guidelines.
3. This service modality is required to meet the essential health needs of the individual; and there is a reasonable expectation of reduction in behaviors/symptoms with medication assisted treatment.
4. The individual has completed or will be referred for a substance abuse assessment for further recommendations and coordination of services as clinically indicated.
5. Completion of a history and physical by the prescribing provider, which includes a determination of the individual’s suitability for this treatment, per Federal prescribing regulations and prevailing clinical standards.
6. Prescribers who participate in Office Based Treatment Programs (OBOT) that offer buprenorphine must have a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver. Treatment provided adheres to all applicable Federal and state laws.
7. All the following must be met:
  1. The individual is willing to adhere to treatment plans and recommendations.
  2. The medication is being used as part of a complete treatment plan that includes an individualized recovery plan including counseling and psychosocial supports.
  3. The individual has a supportive and consistent recovery environment that is supportive of recovery, or individual demonstrates the social/cognitive skills to develop a healthy support system.
8. The individual does not meet any of the exclusion criteria identified in the Exclusion Criteria section below.

Criteria for Continuation of Treatment

All the following must be met:

The individual’s medication dose is safe and adequate.
Progress is documented and the individual is sufficiently cooperative with the treatment plan to meet goals;
Or
If progress is not occurring then the treatment plan is being re-evaluated and refined with medically appropriate goals.
Drug screening results are consistent with treatment adherence, or if unexpectedly positive or negative, have led to treatment plan refinements. Frequency of drug testing is based on individual’s presentation, collateral contacts and federal guidelines. Drug testing is subject to current BCBSND medical policy drug testing guidelines.
There is documentation of ongoing collaborative decision making between treating providers and individual regarding treatment with MAT.
There is documentation of collaboration with other relevant providers on the individual’s care delivery team, for example, dentists, psychiatrists, primary care provider, or substance abuse treatment providers.

Exclusion Criteria:

The individual continues to be actively using mood altering substances without engagement in recovery efforts.
The individual has medical factors identifying them as inappropriate for this treatment, per Federal prescribing regulations or medical necessity standards of care.
The individual is abusing/obtaining opiates from other sources or diverting medication to others, and/or unwilling to participate in treatment plan changes.

Coding and Billing

Used specific to the Delivery of Medication Assisted Treatment:

H0020- Used for Support Services for Methadone OTP
H0020- Window dosing
H0020 - with Modifier 52 take home dosing.
H0047: Used for prescriber practice clinical support/care management
H0047-52 Used with an office E/M code for the purpose of initiating or managing MAT treatment.

Professional Statements and Societal Positions Guidelines

Not Applicable

Links

Not Applicable

ND Review Committee

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 1-19-2021 Coding update:

H0020- Window dosing
H0020 - with Modifier 52 take home dosing.

Internal Medical Policy Committee 1-20-2022 Annual Review

Internal Medical Policy Committee 4-14-2022 System ID; ND-MED-01

Internal Medical Policy Committee 1-26-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 7-26-2023 Archiving - Effective September 04, 2023

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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