1.0 DESCRIPTION
MAT
for a diagnosed Substance Use Disorder (SUD) is a holistic modality
for recovery and treatment that employs evidence-based therapy,
including psychosocial treatments and psychopharmacology, and Food
and Drug Administration (FDA)-approved medications as indicated
for the management of withdrawal symptoms and maintenance.
2.0 POLICY
2.1 MAT is covered
for the treatment of SUDs from both institutional and individual
professional providers. However, certain forms of MAT for treatment
of opioid use disorder (e.g., administration of methadone) are regulated
by the Department Of Health and Human Services’ (DHHS’) 42 CFR 8.12,
the Center for Substance Abuse Treatment (CSAT), and the Drug Enforcement
Administration (DEA), along with individual state and local regulations
(see
Section 3.17). Some MAT services may also
be used to treat SUDs other than opioid use disorder (e.g., Naltrexone
extended release injectable as a commonly prescribed MAT for the
treatment of alcohol use disorder).
2.2 Opioid use disorder may be treated on an
outpatient basis with FDA approved products by qualified, licensed
physicians, Nurse Practitioners (NPs), and Physician Assistants
(PAs). Depending on the medication prescribed, a valid physician
waiver, or NP/PA waiver (respectively), issued under the Controlled
Substances Act, as amended by the Drug Addiction Treatment Act of
2000 (21 United States Code (USC) 823(g)(2)), and verified through
Substance Abuse and Mental Health Services Administration (SAMHSA)
may be required. If required, the qualified physician, NP, or PA
must be registered with the DEA to dispense controlled substances
and in possession of an assigned DEA special identification number.
See
https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator for
a list of all SAMHSA recognized providers.
2.3 In all cases, medical and psychological
necessity must be determined by diagnostic criteria as described
in the current edition of the International Classification of Diseases,
Tenth Revision, Clinical Modification (ICD-10-CM) before MAT is
started.
2.5 Individual
providers of MAT shall bill for their services using normal Evaluation
& Management (E&M) codes. Provision of the MAT pharmaceutical,
when administered via Office-Based Opioid Treatment (OBOT), can
be found under the TRICARE Pharmacy Benefit (TRICARE Operations
Manual (TOM),
Chapter 23).
For MAT pharmaceuticals typically self-administered, see TRM,
Chapter 1, Section 15.
3.0 EXCLUSION
The
programmed use of physical measures, such as electric shock, alcohol,
or other drugs as negative reinforcement (aversion therapy) is not
covered, even if recommended by a physician. Note that Antabuse
is not considered a medication used as aversion therapy.
4.0 EFFECTIVE
DATES
4.1 November
21, 2013, for MAT provided in a Substance Use Disorder Rehabilitation
Facility (SUDRF) only.
4.2 October 3, 2016, for MAT services provided
outside of a SUDRF.