Supplemental Criteria for Mckesson Interqual 2016

September 7, 2016

Supplemental Criteria for McKesson InterQual 2016

Name of Supplemental: Substance Abuse Residential Treatment: Admissions criteria for members prior to administration of an initial dose of Vivitrol®.

Coverage guidelines ______

Members may be considered appropriate for admission to and continued stay in substance abuse residential facility regardless of meeting criteria per the McKesson InterQual® tool when the following criteria are met:

·  The member has an outpatient provider who has determined that Vivitrol® is clinically indicated for treatment of the member’s substance use disorder

·  The member has agreed to treatment with Vivitrol®

·  The member has demonstrated an inability to maintain substance-free for the required time period for Vivitrol® administration (generally 7-10 days opiate free prior to administration of Vivitrol®)

·  The member does not have sufficient social supports and/or resources to allow for the member to remain substance-free in the community

·  The member is in agreement with entering a substance abuse residential facility for the required time period prior to the administration of Vivitrol®

·  The residential facility has assessed the member and is an agreement that residential level of care is appropriate for the time period required prior to the administration of Vivitrol®

Provider Manual Information additions ______

Information to be added to Provider Manual

DVHA Information and Education ______

DVHA utilization review staff must utilize the above criteria as a supplement to the McKesson InterQual criteria for determining continued stay authorization for members admitted to residential treatment for substance use disorders.

DVHA utilization review staff will authorize a time period up to 21 days based on the above criteria and in consideration of the following:

·  Vivitrol® administration requires a 7-10-day authorization for opiate free time prior to administration

·  If members are actively using opiates upon admission to the residential facility, an additional 5-7 days of withdrawal management prior to the 7-10 days should be authorized

·  1-2 days should be authorized prior to the IM Vivitrol® for oral administration of Vivitrol® in order to monitor member tolerance of the medication.

·  1-2 days post Vivitrol® IM administration should be authorized for monitoring of potential injection site reactions.

The authorized length of stay will not exceed 21 days based on this criteria supplement. For authorizations beyond the scope of this supplement, utilization review staff are to refer to McKesson InterQual® criteria

References______

This supplemental criteria set was drafted by and vetted through DVHA and VDH-ADAP clinical staff and was reviewed by a Vermont Medicaid provider currently enrolled and providing addictions treatment services.

This document has been classified as public information.

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