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Medical Policy: 05.01.13
Original Effective Date: September 2006
Reviewed: September 2011
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Naltrexone hydrochloride is an oral opioid antagonist drug used for the treatment of opioid and alcohol dependency. The drug is reported to reduce the cravings for opioids and alcohol in dependant patients but it does not diminish or prevent withdrawal symptoms. It also does not ensure abstinence from alcohol. However, it may decrease patients’ motivation to continue drinking by blocking some of the reinforcing effects of alcohol.
There is now an FDA approved extended release injectable form of this drug for the treatment of alcohol dependency, marketed under the trade name Vivitrol™. It is administered via intramuscular injection by a healthcare professional and the effect lasts for one month.
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Prior Approval:
Not applicable
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Policy:
The use of oral naltrexone for the treatment of opioid or alcohol dependency may be considered medically necessary under medical supervision as part of a comprehensive chemical dependency treatment program.
The use of injectable naltrexone (Vivitrol™) is considered not medically necessary for all applications because there is an equivalent and less expensive form of the drug available for oral administration.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- J2315 Injection, naltrexone, depot form, 1 mg
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Selected References:
- Chick J, Anton R, et al. A multicentre, randomized, double-blind, placebo-controlled trial of naltrexone in the treatment of alcohol dependence or abuse. Alcohol and Alcoholism 2000 Nov-Dec;35(6):587-93.
- Streeton C, Whelan G. Naltrexone, a relapse prevention maintenance treatment of alcohol dependence: a meta-analysis of randomized controlled trials. Alcohol and Alcoholism 2001 Nov-Dec;36(6):544-52.
- Krystal JH, Cramer JA, et al. Naltrexone in the treatment of alcohol dependence. N Engl J Med. 2001 Dec 13;345(24):1734-9.
- Garbutt JC, Kranzler HR, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA. 2005 Apr 6;293(13):1617-25.
- Comer SD, Sullivan MA, et al. Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial. Arch Gen Psychiatry. 2006 Feb;63(2):210-8.
- Anton RF, O'Malley SS, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006 May 3;295(17):2003-17.
- Johnson BA. Naltrexone long-acting formulation in the treatment of alcohol dependence. Ther Clin Risk Manag. 2007 October; 3(5): 741–749.
- Anton RF. Naltrexone for the Management of Alcohol Dependence. N Engl J Med. 2008 Aug 14;359(7):715-721.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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