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December 2016 Texas Medicaid Provider Procedures Manual

Behavioral Health, Rehabilitation, and Case Management Services Handbook : 8 Substance Use Disorder (SUD) Services (Abuse and Dependence) : 8.8 Prior Authorization : 8.8.2 Prior Authorization for Ambulatory (Outpatient) Detoxification Treatment Services : 8.8.2.1 Admission Criteria for Ambulatory (Outpatient) Detoxification Treatment Services

8.8.2.1
To be considered eligible for treatment for ambulatory detoxification services, the client must meet the following conditions:
Chemical Substance Withdrawal
The client must meet all of the following criteria with regard to chemical substance withdrawal:
The diagnosis must meet the criteria for the definition of substance (chemical) dependence, as detailed in the most current revision of the ICD-10-CM, or the most current revision of the Diagnostic and Statistical Manual for Professional Practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.
Medical Functioning
The client must meet all of the following criteria with regard to medical functioning:
No clinical evidence of altered mental state as manifested by disorientation to self, alcoholic hallucinations, toxic psychosis, or altered level of consciousness (clinically significant obtundation, stupor, or coma).
The symptoms are due to withdrawal and not due to a general medical condition. Absence of any presumed new asymmetric or focal findings (i.e., limb weakness, clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema, or localized cerebellar dysfunction, as reflected in asymmetrical limb coordination).
Stable vital signs as interpreted by a physician. The client must also be without a previous history of complications from acute chemical substance withdrawal and judged to be free of a health risk as determined by a physician.
Family, Social, or Academic Dysfunction
The client must meet at least one of the following criteria with regard to family, social, or academic dysfunction:
The client’s social system and significant others are supportive of recovery to the extent that the client can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the client’s addiction.
The client may or may not have a primary or social support system to assist with immediate recovery, but the client has the social skills to obtain such a support system or to become involved in a self-help fellowship.
The client does not live in an environment where licit or illicit mood altering substances are being used. A client living in an environment where licit or illicit mood altering substances are being used may not be a candidate for this level of care.
Emotional and Behavioral Status
The client must meet all of the following criteria with regard to emotional and behavioral status:
The mental state of the client does not preclude the client’s ability to comprehend and understand the materials presented, and the client is able to participate in the ambulatory (outpatient) detoxification treatment process.
Client has no neuropsychiatric condition that places the client at imminent risk of harming self or others (e.g. pathological intoxication or alcohol idiosyncratic intoxication).
Client has no neurological, psychological, or uncontrolled behavior that places the client at imminent risk of harming self or others (depression, anguish, mood fluctuations, overreactions to stress, lower stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, negative emotions, or anxiety).
Client has no documented DSM condition or disorder that, in combination with alcohol or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the client.
Chemical Substance Use
The client must meet the criteria in at least one of the following conditions with regard to recent chemical substance use:
The client’s chemical substance use is excessive, and the client has attempted to reduce or control it but has been unable to do so (as long as chemical substances are available).
The client is motivated to stop using alcohol or drugs and is in need of a supportive, structured treatment program to facilitate withdrawal from chemical substances.

Texas Medicaid & Healthcare Partnership
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