Residential Treatment for Substance Dependence Criteria

1. 1. Severity of illness:

      All of the criteria listed below must be met to meet medical necessity for residential substance dependence treatment: 

      • The patient has a substance related disorder as defined by DSM-V-TR.  
      • The patient is cognitively intact to participate, and will benefit from admission to a residential treatment program.  
      • The patient exhibits a pattern of severe substance abuse/dependency as evidenced by significant impairment in social, familial, scholastic or occupational functioning.
      • One of the following must be met to satisfy this bullet: 
        1. Despite recent, (in the past 3 months) appropriate, professional outpatient intervention, the patient is continually unable to maintain abstinence or recovery.
        2. The patient is residing in a severely dysfunctional living environment which would undermine effective outpatient treatment.
        3. There is evidence for, or reasonable inference of, serious, imminent physical harm to self or others directly attributable to the continued abuse of substances, which would prohibit treatment in an out patient setting.
        4. Patient suffers from another chronic co-morbid mental illness that inhibits patients’ ability to benefit from a lower level of outpatient care.

           Symptoms of the co-morbid mental illness are stabilized to allow participation in treatment program.

      • The patient’s need for detoxification treatment is not of a severity to require an inpatient hospital level of care.
   2. Intensity of Service

      All criteria must be met to meet intensity of service:

      1. Clinically Managed Residential Services (ASAM 3.5)
         • Within 72 hours, a complete biopsychosocial assessment and assignment of a DSM-V-TR diagnosis must result from a face-to-face behavioral health evaluation delivered by a licensed behavioral health provider.  Within 72 hours, a history and physical with medical clearance must be completed and documented by a board certified or board eligible licensed physician.
         • The program provides supervision seven days a week, 24 hours per day, to assist with the development of skills necessary for daily living, to assist with planning and arranging access to a range of educational, therapeutic and aftercare services, and to assist with the development of the adaptive and functional behavior that will allow the patient to live outside of a residential setting
         • The program has on-call availability of medical personnel to respond on-site or by telephone to urgent medical or psychiatric situations 24 hours a day.
         • An individualized plan of active mental health treatment and residential living support is provided.  This plan must include intensive individual, group and family education and therapy in a residential rehabilitative setting, with an expected 4-8 hours of programmed activity each day.  The plan must include weekly family and/or support system involvement, unless there is an identified, valid reason why such a plan is not appropriate or feasible.
         • A discharge plan is initially formulated that is directly linked to the behaviors and/or symptoms that resulted in admission and begins to identify appropriate post-residential treatment resources.  A clinically appropriate appointment will be set up within 7 days of discharge.
      2. Medically Monitored Residential Services (ASAM 3.7)
         • Within 72 hours a multidisciplinary assessment and assignment of a DSM-V-TR diagnosis must result from a face-to-face behavioral health evaluation delivered or supervised by a board certified or board eligible licensed physician. There shall be a licensed physician on call 24 hours a day, 7 days a week. The program shall be staffed by a licensed physician or Advanced Practice Provider. The physician shall review and countersign all medical evaluations, diagnoses and treatment records at least once every 72 hours.
         • The program provides supervision seven days per week/24 hours per day to assist with the development of skills necessary for daily living, to assist with planning and arranging access to a range of educational, therapeutic and aftercare services, and to assist with the development of the adaptive and functional behavior that will allow the patient to live outside of a residential setting.
         • There is sufficient availability of medical and nursing services to manage this patient’s ancillary detoxification needs.
         • An individualized plan of active mental health treatment and residential living support is provided.  This treatment must be medically monitored, with 24 hour medical availability and 24 hour onsite nursing services. This plan must include intensive individual, group and family education and therapy in a residential rehabilitative setting, with an expected 4-8 hours of programmed activity each day. The plan must include weekly family and/or support system involvement, unless there is an identified, valid reason why such a plan is not appropriate or feasible.
         • A discharge plan is initially formulated that is directly linked to the behaviors and/or symptoms that resulted in admission and begins to identify appropriate post-residential treatment resources. A clinically appropriate appointment will be set up within 7 days of discharge.
   3. Continued Treatment:

      All criteria must be met to meet continued treatment:

      • Despite reasonable therapeutic efforts, clinical evidence indicates at least one of the following:
        1. The persistence of symptoms and behaviors that resulted in treatment to a degree that continues to meet the admission criteria (both severity of illness and intensity of service).
        2. The emergence of additional symptoms and behaviors that meet the admission criteria (both severity of illness and intensity of service), including latent or delayed onset of withdrawal symptoms.
        3. That discharge planning, or attempts at therapeutic re-entry into the community have resulted in, or would result in exacerbation of the psychiatric illness to the degree that would necessitate continue treatment.
      • The current or revised treatment plan can be reasonably expected to bring about significant improvement in the presenting or newly defined problem(s).
      • There is evidence of weekly family and/or support system involvement, unless there is an identified, valid reason why such a plan is not appropriate.

Effective: 1/1/2026