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Naloxone and opioid overdose

Naloxone is used to reverse the effects of opioid overdose, and it is eligible for prior authorization justifications when a patient presents with suspected drug overdose and one or more of the following conditions: unexplained coma, unexplained altered mental status, severe or unexplained cardiovascular instability, unexplained metabolic or respiratory acidosis, testing on neonates suspected of prenatal drug exposure, seizures with an undetermined history, monitoring patient compliance during active treatment for substance abuse or dependence, and monitoring for compliance adherence to the treatment plan or illicit drug use in patients under treatment or seeking treatment for a chronic pain condition. Will the claim be denied? The claim for naloxone to treat opioid overdose will likely not be denied, as naloxone is an effective treatment for opioid overdose and is recommended in multiple guidelines, including the AMA Report 2 of the Council on Science and Public Health, the Department of Health and Human Services Morbidity and Mortality Weekly Report on Overdose Deaths, and the Centers for Disease Control Policy Impact report on Prescription Painkiller Overdose Deaths. When is the following treatment medically necessary for the condition specified? Naloxone is typically considered medically necessary for opioid overdose when there are signs of respiratory depression, sedation, and/or decreased level of consciousness. It is also medically necessary for opioid overdose when the patient has an opioid tolerance, is taking a high-dose opioid, and/or is taking an extended-release opioid. What are the relevant codes for the treatment? The HCPCS code for naloxone for opioid overdose is J3490 and the CPT code is 96372.

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