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MP 3.02.01 Methadone Treatment for Opiate Addiction

Medical Policy    
Section
Mental Health
 
Original Policy Date
11/2011
Last Review Status/Date
Created with literature search/11:2011
Issue
11:2011
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 


Description

Methadone hydrochloride is a synthetic narcotic analgesic with multiple actions quantitatively similar to those of morphine. Its principal use is detoxification or maintenance in opiate addiction (heroin or other morphine-like drugs).


Policy

Methadone treatment is medically necessary for the following treatments:

  • The administration of methadone for up to 3 days when the patient is experiencing acute withdrawal symptoms and cannot be immediately referred for chemical dependency treatment.
  • Outpatient Treatment of Opioid Dependence with buprenorphine alone or in combination with naloxone.
  • Intensive Outpatient Programs, Partial Hospital/Day Treatment Programs or routine outpatient settings which provide chemical dependency treatment to patients with substance use disorders other than methadone maintenance.
  • The use of methadone as a treatment for pain disorders.

Methadone treatment as maintenance, L.A.A.M (1-Alpha-Acetyl-Methadol), Cyclazocine, or their equivalents is a noncovered service.

Administration of opioid antagonists under heavy sedation or general anesthesia, as a technique of opioid detoxification is considered investigational. See Medical Policy: 3.01.02 Opiod Antagonists under Heavy Sedation or General Anesthesia as a Technique of Opiod Detoxification


Policy Guidelines

According to the American Society of Addiction Medicine, Methadone
Maintenance Treatment (a.k.a. “Opioid Maintenance Therapy) is an umbrella term that encompasses a variety of pharmacologic and nonpharmacologic treatment modalities including the therapeutic use of specialized opioid compounds such as methadone and LAAM (levo-alpha-acetylmethadol) to psychopharmacologically occupy opiate receptors in the brain, extinguish drug craving and establish a maintenance state. Methadone Maintenance Treatment is typically delivered in an ambulatory setting in accordance with procedures and criteria that are stipulated by state and federal regulations.
Methadone Maintenance Treatment is used to treat Opioid Dependence.
Methadone Maintenance Treatment should not to be confused with any of the following outpatient services:

  • The administration of methadone for up to 3 days when the patient is experiencing acute withdrawal symptoms and cannot be immediately referred for treatment.
  • Outpatient Treatment of Opioid Dependence with buprenorphine alone or in combination with naloxone.
  • Intensive Outpatient Treatment, Partial Hospital/Day Treatment Programs or
    routine outpatient settings which provide treatment to patients with substance
    use disorders other than Methadone Maintenance Treatment.
  • The use of methadone as a treatment for pain.

Methadone Maintenance Treatment is excluded so there are no indications for coverage.

A request for Methadone Maintenance Treatment must be reviewed against the language in the enrollee`s benefit document. When the requested service or procedure is limited or excluded from the enrollee’s benefit document, or is otherwise defined differently, it is the terms of the enrollee's benefit document that prevails. 


Benefit Application

Additional Information: The lack of a specific exclusion of a service does not imply that the service is covered.

Please refer to the enrollee’s benefit document for ASO plans with benefit language other than the generic benefit document language.


Definitions

Methadone Maintenance Treatment An umbrella term that encompasses a variety of pharmacologic and nonpharmacologic treatment modalities including the therapeutic use of specialized opioid compounds such as methadone and LAAM (levo-alpha-acetylmethadol) to psychopharmacologically occupy opiate receptors in the brain, extinguish drug craving and establish a maintenance state.

Opioid Dependence According to the DSM IV, Opioid Dependence is a form of substance use disorder whose essential feature is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems. There is a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drug-taking behavior.

Outpatient Treatment of Opioid Dependence A form of replacement therapy that is administered in a physician’s office where dependence on an opioid is substituted with use of either of three forms of buprenorphine currently approved for this type of use:

  • Buprenorphine HCl sublingual tablets (Subutex®)
  • Buprenorphine HCl with naloxone HCl dehydrate sublingual tablets
  • Buprenorphine and naloxone (Suboxone®) film

References:

  1.  21 CFR, Part 1306.07, Administering or dispensing of narcotic drugs
    http://www.deadiversion.usdoj.gov/21cfr/cfr/1306/1306_07.htm
  2. American Society of Addiction Medicine, Patient Placement Criteria for the
    Treatment of Substance-Related Disorders, Second Edition-Revised

 


Index

Methadone treatment for opiate addiction and pain


Policy History
Date Action Reason
11/30/2011 Add to Behavioral Health section New policy
9/21/12 update only added Suboxone film