The following changes have been made from the previous version:
The American Society of Addiction Medicine (ASAM) describes the impact of opioid use disorder as a chronic, relapsing disease which has significant economic, personal, and public health consequences. ASAM has reported that drug overdose is a national epidemic and is the leading cause of accidental death in the US.
According to the Behavioral Health Trends in the United States: Results from the 2021 National Survey on Drug Use and Health (NSDUH) Results Detailing Mental Illness and Substance Use Levels, published by the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2021:
Methadone Injection [package insert]. Rockford, IL: Mylan Institutional LLC; 01/ 2017. Accessed June 15, 2022.
Methadone Oral Solution [package insert]. Columbus, OH: Roxane Laboratories, Inc.; 06/2021. Accessed June 15, 2022.
Methadone Intensol Concentrate [package insert]. Columbus, OH: Roxane Laboratories, Inc.; 04/ 2021. Accessed June 15, 2022.
Methadose Concentrate [package insert]. Hazelwood, MO: Mallinckrodt Inc.; 09/ 2021. Accessed June 15, 2022.
Methadose Tablets [package insert].Hazelwood, MO: Mallinckrodt Inc.; 09/ 2018. Accessed June 15, 2022.
Methadose Dispersible [package insert]. Hazelwood, MO: Mallinckrodt Inc.; 02/2020. Available at: Methadose ™ Dispersible Tablets 40 mg | Mallinckrodt Pharmaceuticals. Accessed June 15, 2022.
National Academies of Sciences, Engineering, and Medicine. (2019). Medications for Opioid Use Disorder Save Lives. Washington, DC: The National Academies Press. Available at: https://doi.org/10.17226/25310. Accessed September 14, 2022.
Probuphine® (buprenorphine) implant. [prescribing information]. Titan Pharmaceuticals, Inc. South San Francisco, CA; 06/2022. Available at: https://probuphine.com/. Accessed June 15, 2022.
MEDICALLY NECESSARY
G2086 Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month
G2087 Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month
G2088 Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure)
J0570 Buprenorphine implant, 74.2 mg
J2315 Injection, naltrexone, depot form, 1 mg
Q9991 Injection, buprenorphine extended-release (sublocade), less than or equal to 100 mg
Q9992 Injection, buprenorphine extended-release (sublocade), greater than 100 mg
EXPERIMENTAL/INVESTIGATIONAL THE FOLLOWING CODES ARE USED TO REPRESENT NALTREXONE IMPLANTS:
J7999 Compounded drug, not otherwise classified
This version of the policy will become effective 04/10/2023.
This policy has been updated to include the Company's coverage position on buprenorphine injection.
The following provider requirement was removed from medically necessary criteria:
Prescribers must obtain a waiver as per the requirements in the Drug Addiction Treatment Act (DATA) of 2000.
This version of the policy will become effective 01/01/2023
This policy has been updated to include the Company's coverage position on methadone maintenance therapy as Medically Necessary with criteria.
This policy has been reissued in accordance with the Company's annual review process.