CurrentPremera BluecrossPolicy N/A

ASAM Criteria: Services Reviewed for Medical Necessity

Defines medical necessity coverage for inpatient, residential, and detoxification substance use disorder (SUD) services using American Society of Addiction Medicine (ASAM) criteria for Washington fully-insured group and individual plans (with exceptions). Affects providers submitting claims for SUD admissions in applicable Washington plans.

Policy Summary

PayerPremera Bluecross

PolicyASAM Criteria: Services Reviewed for Medical Necessity

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 1, 2024

Next Review DateJan 1, 2025

Key ActionDocument that services meet ASAM criteria to establish medical necessity for inpatient, residential, or detoxification SUD services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

WAApplicable state

Inpatient/Residential/DetoxService types covered

0116-0158,1002Revenue codes listed

F10.10-F19.99Diagnosis codes

Coverage Criteria and Scope

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Services considered medically necessary

Covered when ASAM criteria are met for the service type.

Covered Services: Inpatient substance use disorder rehabilitation; Residential/sub-acute detoxification; Residential substance use disorder treatment; Special populations substance use disorder residential treatment may be considered medically necessary when criteria are met using ASAM criteria.

Applies to adults and adolescents

This policy applies only to Washington plans that are fully-insured group and individual products. It explicitly excludes the Government-Administered Insurance Program (GAIP) and the Indian Self-Insured Health Program (ISHIP). It does not apply to Medicare Advantage or non-applicable plans; coverage remains subject to the member's benefit booklet and plan limitations. (Applies to admissions on or after January 1, 2021 per the policy effective dates and benefit application.)

The policy does not provide a separate, explicit list of services labeled “not medically necessary.” Instead, services are evaluated against the ASAM criteria and member benefit limits: services that do not meet ASAM medical necessity criteria or that fall outside a member's plan benefits are not covered under this policy. Providers should consult the member benefit booklet and document ASAM-based medical necessity to support coverage.

Revenue, HCPCS and Diagnosis Codes

Revenue Codes and HCPCS referencesmixed

0118	Inpatient SUD treatment (rev code)
0128	Inpatient SUD treatment (rev code)
0138	Inpatient SUD treatment (rev code)
0148	Inpatient SUD treatment (rev code)
0158	Inpatient SUD treatment (rev code)
1002	Residential SUD treatment (rev code)
0116	Residential/subacute detoxification; Inpatient detoxification (rev code)
0126	Residential/subacute detoxification; Inpatient detoxification (rev code)
0136	Residential/subacute detoxification; Inpatient detoxification (rev code)
0146	Residential/subacute detoxification; Inpatient detoxification (rev code)

1–10 of 12

1/2

ICD-10 CodesICD-10

F10.10-F16.99	Substance abuse disorder (ICD-10 range)
F18.10-F19.99	Substance abuse disorder (ICD-10 range)

Provider Documentation, Billing, and Utilization Review

Prior Authorization

ASAM-based medical necessity review

For admissions under the applicable Washington plans, services must meet American Society of Addiction Medicine (ASAM) criteria to be considered medically necessary. Billing should follow the payer's guidance and use the appropriate revenue and ICD-10 codes when submitting claims for inpatient, residential, or detoxification services reviewed under ASAM criteria.

Applies to Washington Individual Plans and Washington Fully-Insured Group Plans (except GAIP and ISHIP) for admissions on/after Jan 1, 2021
Document and bill using the revenue and ICD-10 codes appropriate for the level of care rendered

Documentation Required

ASAM documentation requirement

Providers must highlight and ensure documentation demonstrates that the requested level of care meets ASAM criteria. This includes clear clinical justification tying the member's functional impairment, withdrawal risk, and treatment needs to the ASAM dimension(s) that support the admission or continued stay.

Document assessment findings mapped to ASAM dimensions (e.g., acute intoxication/withdrawal potential; biomedical conditions; emotional/behavioral/cognitive conditions; readiness to change; relapse/continued use/continued problem potential; recovery environment)
Include objective measures and clinical notes that support necessity for inpatient, residential, or detox services

Denial Risk

Denial triggers

Services that do not meet ASAM criteria for medical necessity are subject to denial. Admissions or continued stays for inpatient, residential, or detoxification care without documentation meeting ASAM thresholds (for example, insufficient withdrawal risk, inadequate functional impairment, or lack of documented need for that level of care) may be denied.

Common denial triggers: lack of ASAM-based justification, services that are more intensive than clinically indicated, and missing or incomplete ASAM assessments
Ensure records show why lower levels of care are insufficient before admission to higher-intensity settings

Background and Rationale

The American Society of Addiction Medicine (ASAM) criteria are used to match patients to an appropriate level of care for substance use disorders. This policy applies ASAM standards when reviewing medical necessity for admissions to inpatient rehabilitation, residential/sub-acute detoxification, residential SUD treatment, and special-population residential treatment for adults and adolescents. Providers must document that the ASAM admission and continued-stay criteria are met to justify the level of care requested.

Key Definitions

ASAM criteria — Definition and purpose

DefinitionASAM criteria are a set of standards from the American Society of Addiction Medicine used to determine the appropriate level of care for patients with substance use disorders, matching patients to inpatient, residential, or detoxification services.

PurposeTo improve access and quality of care by matching individual patients with the appropriate services to support recovery and to be used by the Plan to review medical necessity for SUD services.

Scope of useApplied to review residential, inpatient, and detoxification services for adults and adolescents when determining medical necessity.

Documentation expectationProviders must document that services meet ASAM admission and continued-stay criteria to justify medical necessity for the level of care requested.

Policy roleThe policy describes which SUD treatment types may be considered medically necessary when ASAM criteria are met; the Introduction explains the intent but specific coverage language appears in the Policy Coverage Criteria.

Residential/sub-acute detoxification — Definition and scope

DefinitionResidential/sub-acute detoxification: residential services focused on withdrawal management and stabilization, listed as a covered service when ASAM criteria are met.

Covered services contextIdentified in the policy Coverage Criteria as one of the services that may be considered medically necessary when ASAM criteria are met (alongside inpatient rehabilitation and residential SUD treatment).

PopulationApplies to adults and adolescents when ASAM admission criteria are met and documented by the provider.

Relation to level-of-care reviewAdmission, continued stay, and discharge decisions for residential/sub-acute detoxification are determined using ASAM criteria and require ongoing documentation that criteria continue to be met.