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.