(1) All Medicaid substance use disorder services must be determined medically necessary by a licensed health care professional within the scope of their Montana professional license.

(2) Medical necessity includes documentation to support:

(a) an appropriate level of care placement for service based upon the American Society of Addiction Medicine (ASAM) Criteria, Third Edition; Copyright 2013 by the American Society of Addiction Medicine, Inc.; http://www.asam.org/publications/the-asam-criteria/text/; and

(b) an International Classification of Diseases – Revision 10 Clinical Modification (ICD-10-CM) diagnosis of a substance use disorder.

(3) All services except assessment services must be based upon a treatment plan established with the member.