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Inpatient Hospitalization

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					                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
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 except in certain limited
                               situations.

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.


               *It is recognized by CompCare that in certain locales for certain members a
               controlled substance abuse treatment intervention may be clinically reasonable.
               Having said this, CompCare does support an abstinence model.

Procedures for Applying UM Criteria
                 Level of Care Guidelines 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
                                                                                      Page 1 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
                                       particular LOC and a particular patient. Therefore, CompCare
                                       considers at least the following factors when applying criteria to a
                                       given individual:
•      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 is 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




                                                                                      Page 2 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
                                              SUBSTANCE ABUSE OUTPATIENT TREATMENT

Organized outpatient treatment for adults 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 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 functional 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 member,
3) an option to engage and enhance the motivation of a resistant member who is not ready
to commit to recovery and is in the early stages of change, or 4) an additional level of
support for a member who has had limited success within a structured treatment program.

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 social service agency interventions.

Admission: Substance Abuse 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 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 The member’s family and environment can support recovery with limited assistance.

E         The member suffers from minimal to mild impairment in social, medical, family
          and/or work functioning secondary to substance abuse.
                                                                                      Page 3 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
F         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 lead to passive
          compliance, increased conflict, withdrawal from treatment or be counterproductive.

Continued Stay: Substance Abuse Outpatient Treatment

1. Must meet BOTH
A The member and when indicated, family 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.


Discharge: Substance Abuse 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 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
                                   SUBSTANCE ABUSE INTENSIVE OUTPATIENT TREATMENT

Intensive Outpatient treatment for chemical dependency is usually built around a
structured program run by professional staff trained in the treatment of chemical
dependency.

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 the first treatment option for members with support systems or use of
a sober living environment and absence of significant physical and psychiatric
complications. 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 of attendance should be
continually adjusted based on severity of signs and symptoms.

Admission: Substance Abuse 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 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 is 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.




                                                                                      Page 5 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
Continued Stay: Substance Abuse Intensive Outpatient Treatment
1. Must be met
    Must meet medical necessity for continued stay

2. Must meet ALL
A The member has 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: Substance Abuse 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.




                                                                                      Page 6 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
                                      AMBULATORY DRUG AND ALCOHOL DETOXIFICATION

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, 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
         monitoring with 24 hour access to a physician should symptoms worsen.
A The member is at risk for a severe withdrawal syndrome evidenced by a set of
2 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
         monitoring with 24 hour access to a physician should symptoms worsen.
                                                                                      Page 7 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
B         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 meet
A Continued stay guidelines are no longer met.




                                                                                      Page 8 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
                                             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.
Multifamily groups are considered in addition to scheduled family therapy for the
individual member and his/her family.

Admission: Substance Abuse 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
                                                                                      Page 9 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
          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: Substance Abuse Partial Hospitalization
1. Must be met
    Continues to meet admission and medical necessity criteria

1. 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: Substance Abuse 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 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult


                                                    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.

Initial Inpatient (Drug & Alcohol) DETOX Authorization
1. Must be met
       Must meet medical necessity

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 sedative-
      hypnotic 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
          care and medical intervention on a daily basis.
A     The member is at risk for a severe withdrawal syndrome evidenced by a set of symptoms
2     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.
                                                    &
      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
                                                                                     Page 11 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
                Require active treatment that can only be provided by around – the – clock nursing
                care and medical intervention on a daily basis.
B           History of prior complicated and potentially life-threatening withdrawal such as seizures,
            delirium tremens or acute psychotic symptoms.
C           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.


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 12 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult


                                                    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.

Admission: Inpatient Substance Abuse 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.
                                                                                     Page 13 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information
                                             Comprehensive Behavioral Care, Inc.
                                                 Level of Care Guidelines
                                                     Substance Abuse
                                                           Adult
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 Substance Abuse 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 Substance Abuse 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 14 of 14
Approved: SE: UM 6/19/03; QI 6/27/03; Central: UM 6/19/03; QI 6/20/03; SW: UM 7/17/03; QI 7/24/03; Centralized Quality Council: 7/17/03; CompCare BOD: 7/17/03; Reviewed, Revised, Approved:
Quality Committee 6/28/2004; CompCare BOD: 7/29/2004; Reviewed, Revised, Approved: Quality Advisory Council 7/11/2005; Reviewed, Approved: Quality Advisory Council 06/23/2006; Reviewed,
approved Qaulity Advisory Council 0824/07, Reviewed and approved Peer Review Committee 8/22/08 & Quality Advisory Council 9/29/08
CompCare Proprietary Information

				
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