Medically Supervised Withdrawal Management (Detoxification) services authorizations

The term "medical necessity" is used to mean care that is determined to be effective, appropriate and necessary to treat a given patient's disorder. To determine medical necessity for substance use disorder medically supervised withdrawal management (detoxification) the Priority Health Behavioral Health department relies on InterQual^® Behavioral Health criteria and Priority Health medical policies:

• Medical Necessity - 91447
• Medically Supervised Withdrawal Management (Detoxification) - 91104

Members must meet InterQual^® Behavioral Health medical necessity criteria for admission to a substance use disorder facility.

We also require ongoing clinical reviews to ensure that the member continues to meet medical necessity criteria for treatment.

In network providers

Submit authorizations through GuidingCare.

Request an authorization

Out of network providers

If you're located within the state of Michigan and would like to join our network, visit our credentialing page.

Out-of-network providers request mental health and substance use disorder services using our behavioral health authorization form.

The following information is needed:

• Substance use info including substances being abused, first use, last use, amount/frequency of use, pattern of use, periods of sobriety, etc.
• Medical complications related to use
• Current withdrawal symptoms
• Vital signs at admission
• Risk factors
• Treatment history
• Mental health history
• Psychosocial Assessment
• Level of motivation and stage of change
• Clinical Recommendation

We also require ongoing clinical reviews to determine if the member continues to meet medical necessity criteria for treatment.