Medical policy: Substance Use Disorder Site of Service

Número de política: MP 4.052

Fecha de entrada en vigor: 5/1/2026

Política

Note: Substance Use Disorder (SUD) treatment must meet applicable medical necessity criteria for coverage. When coverage criteria are met for the proposed treatment, this policy is used to determine the medical necessity of the requested site of care.

This policy applies solely to Pennsylvania residents.

Out of state SUD treatment will only be authorized if criteria are met and one or more of the following conditions are documented:

Service unavailability in-state

• Required ASAM level or specialty capability (e.g., co-occurring enhanced 3.7 with on-site psychiatry, pregnancy-capable SUD residential, ASL-capable program, programs designed for specific professions) is not available or capacity is exhausted in network in programs or facilities that provide substance use disorder treatment in-state, within medically reasonable timeframes.

Clinical specialty/complexity

• The patient needs specialized services that are not available in any program or facility that provides substance use disorder treatment in-state (e.g., severe medical comorbidity needing integrated 3.7 BIO/4.0; complex dual-diagnosis with violent/self-harm risk requiring higher staffing ratios).
• When located out of state, the patient’s medical and behavioral health condition presents an imminent risk of harm and does not allow safe transport to Pennsylvania without compromising treatment outcomes.

Objective recovery environment risks

• There are immediate safety threats (e.g., stalking, trafficking, violent household) or active local triggers tied to overdose/relapse, where geographic separation is clinically justified and lesser measures (safe housing, recovery residences) are inadequate or unavailable. Document why in-state alternatives cannot adequately mitigate risk.

Continuidad de la atención médica

• Step-up/step-down continuity within the same multi-level program demonstrably improves outcomes and is unavailable in-state.

Directrices de la política

Pediatric/adolescent considerations

Until ASAM publishes the Adolescent and Transition-Age Youth 4th Edition volume, apply 3rd Edition adolescent standards. Document developmental factors, family involvement, and school coordination.

Variaciones del producto

This policy applies exclusively to individual accounts.

This policy is only applicable to Individual health plans issued by Capital Blue Cross and/or its subsidiaries.

Descripción/antecedentes

This policy establishes clear criteria for authorizing out-of-state SUD treatment services, ensuring such services are approved only when medically necessary and when appropriate in-state options to provide SUD treatment are unavailable or insufficient. Determinations of medical necessity must be based on the ASAM Criteria, applied comprehensively to assess the individual's clinical needs, risk factors, functional impairments, and required level of care.

In all cases, in-state treatment is clinically preferred and presumptive option, and out-of-state services may be authorized only if supported by documentation sufficient to demonstrate that the criteria set forth in this policy are met.

This policy is intended to work in conjunction with the ASAM Criteria, ensuring that decisions regarding out-of-state SUD treatment are consistent, medically justified, evidence-based, and aligned with best-practice clinical guidelines.

Fundamento

Centering care on patients means that it is unethical to recruit patients to out-of-state programs when appropriate local options are available. This is particularly critical for more intensive levels of care (e.g., levels 3.5, 3.7, and 4.0) since new clinical needs can make travel dangerous. Urgent out-of-state care may be appropriate when a person has a medical emergency while traveling or requires specialty care that is not locally available-for example a pilot with low blood glucose best served in a program with other pilots or a patient with a severe eating disorder who would be best served in a COE program that specializes in eating disorders. Providers can coordinate with health plan managers to assist in identifying available providers and programs in these circumstances; however, purposely recruiting patients for inappropriate or unnecessary out-of-state treatment can be harmful.

Treatment programs that receive inquiries from the patient or family regarding out-of-state care should obtain the patient's consent for the program's senior medical clinician to communicate directly with the patient's current treatment provider to ensure that no acute medical or psychiatric needs are present that would make travel dangerous. Once the patient's consent has been granted, the program should work directly with the patient and payer to determine if appropriate treatment is locally available. If local treatment is available, the out-of-state program should work directly with the patient and payer to facilitate prompt admission to the local facility.

Out-of-state treatment should only occur when a patient and their current treatment providers have determined that the local options are insufficient, and out-of-state programs offer specialized care that is not locally available. The provider of out-of-state care should have a process of obtaining the patient's informed consent which should include discerning if the payer will reimburse for the out-of-state service and the amount of financial obligation which will fall to the patient. [1]

Definiciones

In-state: Located within the state of Pennsylvania.

Out-of-state: Located outside the state of Pennsylvania.

Pennsylvania resident: A person whose true, fixed, and permanent home, to which that person intends to return whenever absent, is located within the state of Pennsylvania.

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen un consejo médico y están sujetas a cambios según lo permita la ley o la evidencia clínica aplicable de las pautas de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas políticas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios del miembro, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Nota: Es posible que esta lista de códigos no sea exhaustiva y que los códigos estén sujetos a cambios en cualquier momento. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

Specific procedure coding does not apply to this policy.

Referencias

1. American Society of Addiction Medicine. (2023). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions (4th ed.).