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TITLE 28INSURANCE
PART 1TEXAS DEPARTMENT OF INSURANCE
CHAPTER 3LIFE, ACCIDENT, AND HEALTH INSURANCE AND ANNUITIES
SUBCHAPTER HHSTANDARDS FOR REASONABLE COST CONTROL AND UTILIZATION REVIEW FOR CHEMICAL DEPENDENCY TREATMENT CENTERS
RULE §3.8027Admission Criteria for Outpatient Detoxification Treatment Service

An individual is considered eligible for treatment in an outpatient detoxification treatment service when the individual meets the conditions of paragraphs (1) and (2) of this subsection.

  (1) The diagnosis must meet the criteria for the definition of substance (chemical) dependence, as detailed in the most current revision of the international classification of diseases, or the most current revision of the diagnostic and statistical manual for professional practitioners, accompanied by evidence that some of the symptoms have persisted for at least one month or have occurred repeatedly over a longer period of time.

  (2) Once the diagnostic criteria for substance (chemical) dependency as described in subsection (1) have been met, the conditions of all subparagraphs (A)-(D) of this paragraph must also be met.

    (A) Category 1: chemical substance withdrawal. The individual is expected to have a stable withdrawal from alcohol/drugs.

    (B) Category 2: medical functioning. The patient must meet all the criteria in clauses (i)-(viii) of this subparagraph.

      (i) No history of recent seizures or past history of seizures on withdrawal,

      (ii) Lack clinical evidence of altered mental state as manifested by:

        (I) disorientation to self,

        (II) alcoholic hallucinations,

        (III) toxic psychosis,

        (IV) altered level of consciousness, as manifested by clinical significant obtundation, stupor, or coma.

      (iii) The symptoms are not due to a general medical condition.

      (iv) Absence of any presumed new asymmetric and/or focal findings (i.e., limb weakness, clonus, spasticity, unequal pupils, facial asymmetry, eye ocular movement paresis, papilledema, or localized cerebellar dysfunction, as reflected in asymmetrical limb coordination).

      (v) The patient must have vital signs interpreted by a physician to be stable, without a previous history of complications from acute chemical substance withdrawal, and judged to be free of a physician-determined health risk.

      (vi) The patient has no evidence of a coexisting serious injury or systemic illness, newly discovered or progressive in nature.

      (vii) Absence of serious disulfiram-alcohol (Antabuse) reaction with hypothermia, chest pains, arrhythmia or hypotension.

      (viii) The patient's clinical condition allows for a comprehensive and satisfactory assessment of items cited in clauses (i)-(vii) of this subparagraph and paragraphs (A)-(D).

    (C) Category 3: family, social, academic dysfunction. The patient must meet the criteria of at least one clause out of clauses (i)-(iv) of this subparagraph.

      (i) The patient's social system and significant others are supportive of recovery to the extent that the patient can adhere to a treatment plan and treatment service schedules without substantial risk of reactivating the patient's addiction.

      (ii) The patient's family and/or significant others are willing to participate in the outpatient detoxification treatment program.

      (iii) The patient may or may not have a primary or social support system to assist with immediate recovery, but has the social skills to obtain such a support system and/or to become involved in a self-help fellowship.

      (iv) The patient's living environment should be considered as a factor. An individual living in an environment where licit or illicit mood altering substances are being used may not be a candidate for this level of care.

    (D) Category 4: emotional/behavioral status. The patient must meet all the criteria under clauses (i)-(vii) of this subparagraph.

      (i) Patient is coherent, rational and oriented for treatment.

      (ii) Mental state of the patient does not preclude the patient's ability to :

        (I) comprehend and understand the materials presented; and

        (II) participate in outpatient detoxification treatment process.

      (iii) There is documentation that the patient expresses an interest to work toward outpatient detoxification treatment goals.

      (iv) Patient has no neuropsychiatric condition that places the client at imminent risk of harming self or others (e.g. pathological intoxication, alcohol idiosyncratic intoxication, etc.),

      (v) Patient has no neurological, psychological, or uncontrolled behavior that places the individual at imminent risk of harming self or others (depression, anguish, mood fluctuations, overreactions to stress, lower stress tolerance, impaired ability to concentrate, limited attention span, high level of distractibility, negative emotions, anxiety, etc.).

      (vi) Patient has no documented DSM-IV axis I condition or disorder which, in combination with alcohol and/or drug use, compounds a pre-existing or concurrent emotional or behavioral disorder and presents a major risk to the patient.

      (vii) The patient has no mental confusion and/or fluctuating orientation.

    (E) Category 5: recent chemical substance use. The patient must meet the criteria in at least one clause out of clauses (i) and (ii) of this subparagraph.

      (i) The patient's chemical substance use is excessive, and the patient has attempted to reduce or control it, but has been unable to do so (as long as chemical substances are available).

      (ii) The patient is motivated to stop using alcohol/drugs, and is in need of a supportive structured treatment program to facilitate withdrawal from chemical substances.


Source Note: The provisions of this §3.8027 adopted to be effective February 14, 1999, 24 TexReg 713

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