Opioid Treatment Programs

Jurisdiction: JM Part B. States: North Carolina, South Carolina, Virginia, West Virginia. Type: Active LCD

OTP treatment is considered reasonable and necessary for beneficiaries meeting all of the following requirements: diagnosed with OUD using the Diagnostic and Statistical Manual for Mental Disorders, AND voluntarily chooses maintenance treatment, AND is currently addicted to an opioid drug Initial assessment: Upon admission to the OTP and before initiating pharmacotherapy, the beneficiary must undergo an initial assessment as part of the intake activities that complies with 42 CFR 8.12 (f)(2) and (4). To qualify as an initial assessment the following must be addressed and included in the documentation: Confirmation of the OUD diagnosis Complete medical history inclusive of concomitant medical conditions, psychiatric disorders, trauma, infectious disease, and pregnancy Physical exam (unless assessment is performed via telehealth) Mental health screening for psychiatric disorders Laboratory testing to include complete blood count, liver enzyme testing, tuberculosis screening, hepatitis B + C, and HIV. If laboratory testing is not performed, documentation of recent testing or the rationale for not testing must be included. Authenticated informed consent inclusive of treatment options discussed, risk/benefit consideration of pharmacotherapy, and the patient’s preferences for therapy. Formation of treatment plan with discussion of psychosocial treatment, support, and patient’s preference for these services. Assessment of withdrawal potential and the associated plan. Assessment of safety including overdose potential, prevention education, and offer of take-home naloxone. Drug Testing: Testing for drugs of abuse must be provided in accordance with 42 CFR 8.12(f)(6). The use of other addictive drugs of abuse should not be a reason to withhold or suspend OUD treatment. However, those who are actively using substances during OTP are likely to require greater support including a more intensive level of care. Periodic assessments are required in accordance with 42 CFR 8.12(f)(4). Periodic assessments must include documentation of the following: Evaluation of treatment progress and appropriate adjustments in therapy Review of drug abuse testing and assessment of compliance Review of psychosocial needs and plan to address unmet needs (if any) Documentation that substantiates necessity for a periodic visit Covered Providers: Care must be provided by one or a combination of the following providers and take place as part of a certified opioid treatment program as delineated in 42 CFR 8.11: Physicians (MD/DO) Clinical psychologists Licensed Clinical Social Workers Nurse practitioners Clinical Nurse Specialists Physician Assistants Other providers of mental health services licensed or otherwise authorized by the state in which they practice (e.g., licensed professional counselors, licensed clinical alcohol and drug counselors, licensed marriage and family therapists, licensed clinical alcohol and drug counselors, certified peer specialists) Duration of treatment: There is no limitation to the duration of treatment. All coverage criteria must be clearly documented in the patient’s medical record and made available to the A/B MAC upon request.