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    v1.0.30
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthPriority Health Medicare Detox Coverage | OpenPaye…
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    CurrentPriority Health MedicarePolicy 91104

    Medically Supervised Withdrawal Management (Detoxification)

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    This policy governs coverage and medical necessity for acute inpatient medical and psychological care to manage acute withdrawal from alcohol or other substances. General substance use disorder treatment is outside the policy scope, and coverage remains subject to the member’s specific benefits and applicable plan documents.

    Policy Summary
    PayerPriority Health Medicare
    PolicyMedically Supervised Withdrawal Management (Detoxification)
    Policy CodePolicy 91104
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateSep 1, 2026
    Last ReviewAug 12, 2026
    Next Review DateN/A
    Key ActionFor an emergency admission, notify Priority Health as soon as reasonably possible and provide clinical information for authorization review.
    SourceLink
    POLICY UPDATE CHANGES

    The policy added completed tables for guidelines/position statements and U.S. Food and Drug Administration regulatory information.

    The policy was converted to a new, expanded template.

    Acute inpatientPrimary covered level of care
    24/7Provider and nursing availability
    3-10 daysTypical withdrawal-management duration

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Not covered
    Medicaid/Healthy Michigan Plan detoxification coverage
    Intoxication aloneInsufficient indication for admission
    No changesMedical necessity criteria changes

    Medical Necessity and Coverage Criteria

    Acute Inpatient Medical Necessity

    Acute inpatient medically supervised withdrawal management may be medically necessary when at least one of the following applies:

    ONE of the following

    • There is a need for medical management of withdrawal symptoms.

    • Concomitant medical condition

      • A concomitant medical condition is present that might itself require hospitalization, as determined by a participating provider.

      • Examples include

        • Cardiac arrhythmias.
        • Gastrointestinal hemorrhage requiring transfusion or fluids.
        • Hepatic encephalopathy.
        • Disorientation, altered level of consciousness, or delusions or hallucinations with risk of danger to self or others.
        • Recurrent blackouts within the past 2 weeks.
        • Recent recurrent seizures.
        • Asymmetric or focal neurological findings.
        • Abnormal vital signs, such as symptomatic hypotension despite fluid rehydration.

    Licensed Provider and Nursing Availability

    Acute inpatient withdrawal management facilities must maintain the following staffing and availability requirements:

    ALL of the following

    • A licensed physician/provider is staffed and available on-call around the clock.
    • On-site nursing services are available 24 hours per day for beneficiaries in the detoxification process who require medications to manage the current crisis.

      For emergency admissions, Priority Health must be notified as soon as reasonably possible so clinical information can be reviewed for authorization.

    Continued Stay

    Extensions to the length of stay are reviewed to determine whether the services remain medically supervised withdrawal management rather than treatment of drug dependency.

    ALL of the following

    • The continued services are for medically supervised withdrawal management (detoxification), not treatment of drug dependency.
    • Admission and continuing-stay criteria are evaluated using InterQual® level-of-care criteria by utilization review associates.
    • Withdrawal management is not always followed by substance use disorder treatment, and not all patients entering treatment programs require withdrawal management.

    Intoxication alone is not an indication for admission.

    Patients who are severely intoxicated but do not have a medical complication should be detoxified in a sub-acute facility rather than an acute inpatient hospital setting.

    General substance use disorder treatment is outside the scope of this medical policy. This policy addresses medically supervised withdrawal management (detoxification), meaning acute inpatient medical and psychological care for patients experiencing withdrawal symptoms after ceasing or reducing substance use.

    Admission solely for intoxication, without a qualifying need for medically supervised withdrawal management or a concomitant medical condition requiring hospitalization, is not covered as acute inpatient withdrawal management.

    Acute inpatient detoxification is not medically necessary for severe intoxication without a medical complication; these patients should receive detoxification in a sub-acute facility.

    Applicable Diagnosis and Revenue Codes

    ICD-10 Codes That May Support Medical NecessityICD-10
    F10.231Alcohol dependence with withdrawal delirium
    G45.1Carotid artery syndrome (hemispheric)
    G45.2Multiple and bilateral precerebral artery syndromes
    G45.8Other transient cerebral ischemic attacks and related syndromes
    G45.9Transient cerebral ischemic attack, unspecified
    G46.0Middle cerebral artery syndrome
    G46.1Anterior cerebral artery syndrome
    G46.2Posterior cerebral artery syndrome
    I46.2Cardiac arrest due to underlying cardiac condition
    I46.8Cardiac arrest due to other underlying condition
    1–10 of 28
    1/3
    Revenue Codes IP OnlyRevenue
    0110Room & Board - Private - General
    0111Room & Board - Private - Medical/Surgical/GYN
    0120Room & Board - Semiprivate
    0121Room & Board - Semiprivate - Medical/Surgical/GYN
    0130Room & Board - Three and Four Beds - General
    0131Room & Board - Three and Four Beds - Medical/Surgical/GYN
    0200Intensive Care Unit - General
    0201Intensive Care Unit - Surgical
    0202Intensive Care Unit - Medical
    Non-medical Detoxification Revenue CodesRevenue
    0116Room & Board - Private - Detoxification
    0126Room & Board - Semi-Private Two Bed - Detoxification
    0136Semi-Private - Three & Four Beds - Detoxification
    0146Private (Deluxe) - Detoxification
    0156Room & Board Ward - Detoxification

    Authorization, Documentation, and Coverage Alerts

    Prior Authorization

    Emergency Admission Notification

    For an emergency admission for medically supervised withdrawal management, notify Priority Health as soon as reasonably possible and provide clinical information for authorization review.

    Prior Authorization

    Authorization Request

    Prior authorization may be required for medically supervised withdrawal management services. When required, providers must submit an authorization request demonstrating that the requested service is medically necessary. Refer to the Priority Health Provider Manual and use Priority Health Prism to access InterQual® authorization criteria.

    • Check Priority Health Prism: Authorizations → Authorization Criteria Lookup.
    • Follow the Priority Health Provider Manual guidance for medically supervised withdrawal management authorizations.

    Policy Background

    Medically supervised withdrawal management, also called detoxification, safely manages acute withdrawal from alcohol or other substances through medical assessment, monitoring, symptom management, pharmacologic intervention, supportive care, and transition to ongoing treatment. It addresses the immediate withdrawal episode and does not resolve the longstanding psychological, social, and behavioral problems associated with substance use disorder; longer-term substance use disorder treatment focuses on recovery, behavioral change, relapse prevention, and improved functioning.

    Key Terms

    Medically supervised withdrawal management (detoxification)
    DefinitionAcute inpatient medical and psychological care for patients experiencing withdrawal symptoms after ceasing or reducing substance use.
    Primary purposeSafely manage acute withdrawal symptoms, reduce physiological harm, and prepare the individual for entry into long-term treatment.
    Typical careMedical assessment and monitoring, pharmacologic symptom management, supportive care, and referral to ongoing substance use disorder treatment.
    Typical durationShort-term, typically 3–10 days.
    ScopeThis policy addresses acute inpatient medical and psychological care for withdrawal management; it does not resolve longstanding psychological, social, or behavioral problems associated with substance use disorder.
    Substance use disorder treatment

    Acute and Sub-Acute Detoxification Levels

    Policy Summary
    PayerPriority Health Medicare
    PolicyMedically Supervised Withdrawal Management (Detoxification)
    Policy CodePolicy 91104
    Change TypeAdministrative updateno material clinical or coverage changes
    Effective DateSep 1, 2026
    Last ReviewAug 12, 2026
    Next Review DateN/A
    Key ActionFor an emergency admission, notify Priority Health as soon as reasonably possible and provide clinical information for authorization review.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaApplicable Diagnosis and Revenue CodesAuthorization, Documentation, and Coverage AlertsPolicy BackgroundKey TermsAcute and Sub-Acute Detoxification Levels
    Prior Authorization

    Individual Consideration Requires Prior Approval

    Individual case review may allow coverage for care or treatment that is investigational yet promising for the conditions described. Requests for individual consideration require prior plan approval, and determinations are made by a Priority Health medical director or clinical pharmacist.

    • Coverage exceptions for experimental, investigational, or unproven treatment may be reviewed for terminal illness or chronic, life-threatening, severely disabling disease causing serious clinical deterioration.
    • Obtain plan approval before providing treatment under individual consideration.

    Unsupported block type: documentation

    Unsupported block type: documentation

    Denial Risk

    Intoxication Alone Does Not Qualify

    Intoxication alone is not an indication for admission. Acute inpatient coverage is at denial risk when the member has no qualifying withdrawal-management need and no concomitant medical condition requiring hospitalization.

    • Document a medically supervised withdrawal-management need or a qualifying concomitant condition rather than intoxication alone.

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Billing Rule

    Medicaid Coverage Exclusion

    Acute-care and sub-acute facility detoxification are not covered by Priority Health for Medicaid/Healthy Michigan Plan members. Inpatient detoxification is reimbursed directly by MDHHS fee-for-service, while sub-acute detoxification and substance use disorder residential treatment are authorized by the member’s county PIHP.

    • Confirm the member’s Medicaid/Healthy Michigan Plan status and applicable payer pathway before admission or billing.
    • Refer sub-acute detoxification and substance use disorder residential treatment authorization to the PIHP in the member’s county of residence.
    DefinitionOngoing therapeutic services intended to promote recovery, behavioral change, relapse prevention, and improved functioning after or apart from withdrawal management.
    Primary purposeAddress underlying addiction and promote sustained recovery, rather than manage acute withdrawal symptoms.
    Typical servicesTherapy, counseling, medication-assisted treatment, and support services.
    Typical durationLong-term, typically weeks to months or more.
    Policy distinctionGeneral substance use disorder treatment is outside the scope of this medical policy; continued services must remain medically supervised withdrawal management rather than treatment of drug dependency.