Clinical UM Guideline


Subject:Psychiatric Disorder Treatment
Guideline #:  CG-BEH-03Current Effective Date:  10/14/2014
Status:RevisedLast Review Date:  08/14/2014

Description

This document addresses the medical necessity criteria for levels of care relating to psychiatric disorder treatment and psychiatric outpatient treatment (including treatment provided by a clinician licensed at the independent practice level) and medication management. This document does not address Applied Behavior Analysis (ABA) or ABA therapy.

The medical necessity criteria outlined in this document for each level of care relating to psychiatric disorder treatment includes three categories; Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria includes descriptions of the member's condition and circumstances. Intensity of Service criteria describes the services being provided and these criteria must be met for admission and continued stay. For continued authorization of the requested service, Continued Stay criteria must be met along with Severity of Illness criteria.

This document addresses psychiatric disorder treatment for:

Note: Please see the following related documents for additional information:

Clinical Indications

Acute Inpatient

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) Diagnosis that is consistent with symptoms and the primary focus of treatment is acute inpatient psychiatric care.

Severity of Illness (SI)
Must have one of the following:

  1. Imminent suicidal risk or danger to others – immediate danger to self and/or others is apparent or behavior indicating a plan that would result in risk to self or others, such that the degree of intent, method, and immediacy of the plan requires a restrictive inpatient setting with psychiatric medical management and nursing interventions on a 24-hour basis; OR
  2. Presence of acute psychotic symptoms severe clinical manifestations, symptoms or complications that creates immediate risk to self or others due to impairment in judgment which preclude diagnostic assessment and appropriate treatment in a less intensive treatment setting and require 24-hour nursing/medical assessment, intervention and/or monitoring; OR
  3. Grave disability acute impairment exists, as evidenced by severe and rapid decrease in level of functioning in several areas of life (work, family, activities of daily living [ADL's], interpersonal), to the degree that the member is unable to care for him or herself, and therefore an imminent danger to themselves or others which precludes diagnostic assessment and appropriate treatment in a less intensive treatment setting and require 24-hour nursing/medical assessment, intervention and/or monitoring; OR
  4. Self-injury or uncontrolled risk taking behaviors or uncontrollable destructive behavior creating immediate risk to self or others which requires medical intervention and containment in a 24-hour a day acute setting.

Intensity of Service (IS)
Must have all of the following components to qualify for Acute Inpatient:

  1. Multi-disciplinary assessment with a treatment plan which addresses psychological, social, medical, and substance abuse needs; AND
  2. Documentation of blood and/or urine drug screen results upon admission and as appropriate; AND
  3. Attending Physician visits at least daily, seven days a week; AND
  4. Medication evaluation and documented rationale if no medication is prescribed; AND
  5. Family assessment and therapy when appropriate. For children and adolescents, a minimum of one to two times per week with an initial family session expected to occur within the first 72 hours of admission, unless clinically contraindicated; AND
  6. Suicide/homicide precautions as required; AND
  7. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans; AND
  8. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the member's primary care physician (PCP), providing treatment to the member, and where indicated, clinicians providing treatment to other family members, is documented.

Continued Stay Criteria (CS)
Must continue to meet "SI/IS" Criteria and have all of the following to qualify:

  1. Progress in treatment is documented. If progress (clinical improvement) is not occurring, the treatment plan is being re-evaluated and amended in a timely and medically appropriate manner; AND
  2. The treatment being delivered is likely to stabilize the symptoms/behaviors that required admission; AND
  3. If voluntary, the member is cooperating with treatment; if the member is involuntary and not cooperating with treatment, the provider has acted in a timely fashion to get legal permission to treat the symptoms/behaviors that required admission; AND
  4. There is a reasonable expectation that the member's illness, condition or level of functioning that required admission is likely to stabilize so that that treatment can be continued at a lower level of care. Custodial care is not typically a Covered Service.

Not Medically Necessary:

Acute inpatient psychiatric care is considered not medically necessary when the above criteria are not met.

 

Residential Treatment Center (RTC)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Diagnosis that is consistent with symptoms and the primary focus of treatment is residential treatment center (RTC) psychiatric care.

Severity of Illness (SI)
Must have all of the following to qualify:

  1. The member is manifesting symptoms and behaviors which represent a deterioration from their usual status and include either self injurious or risk taking behaviors that risk serious harm and cannot be managed outside of a 24 hour structured setting or other appropriate outpatient setting; AND
  2. The social environment is characterized by temporary stressors or limitations that would undermine treatment that could potentially be improved with treatment while the member is in the residential facility; AND
  3. There should be a reasonable expectation that the illness, condition or level of functioning will be stabilized and improved and that a short term, subacute residential treatment service will have a likely benefit on the behaviors/symptoms that required this level of care, and that the member will be able to return to outpatient treatment.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Residential treatment takes place in a structured facility-based setting. Wilderness programs are not considered residential treatment; AND
  2. Documentation shows that a blood or urine drug screen was done on admission and during treatment if indicated; AND
  3. Evaluation by a qualified physician done within 48 hours, and physical exam and lab tests unless done prior to admission, and eight hour on-site nursing (by either a registered nurse [RN] or licensed vocational nurse/licensed practical nurse [LVN/LPN]) with 24 hour medical availability to manage medical problems if medical instability identified as a reason for admission to this level of care; AND
  4. Within 72 hours, a multidisciplinary assessment with an individualized problem-focused treatment plan completed, addressing psychiatric, academic, social, medical, family and substance use needs; AND
  5. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the member's PCP, providing treatment to the member, and where indicated, clinicians providing treatment to other family members, is documented; AND
  6. Treatment would include the following at least once a day and each lasting 60-90 minutes: community/milieu group therapy, group psychotherapy, and activity group therapy; AND
  7. Skilled nursing care (either an RN or LVN/LPN) available on-site at least eight hours daily with 24 hour availability; AND
  8. Individual treatment with a qualified physician at least once a week including medication management if indicated; AND
  9. Individual treatment with a licensed behavioral health clinician at least once a week; AND
  10. Unless contraindicated, family members participate in development of the treatment plan, participate in family program and groups and receive family therapy at least once a week, including in-person family therapy at least once a month if the provider is not geographically accessible. For adolescents, this includes weekly individual family therapy, unless clinically contraindicated; AND
  11. A discharge plan is completed within one week that includes who the outpatient providers will be and where the member will reside; AND
  12. The treatment is individualized and not determined by a programmatic timeframe. It is expected that members will be prepared to receive the majority of their treatment in a community setting; AND
  13. Medication evaluation and documented rationale if no medication is prescribed.

Continued Stay Criteria (CS)
Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. SI criteria are still met and likelihood of benefit and return to outpatient (OP) treatment is shown by adherence to the treatment plan and recommendations by the member and by progress in treatment; if progress is not occurring then the treatment plan is being amended in a timely and medically appropriate manner with treatment goals still achievable.

Not Medically Necessary:

Residential treatment center psychiatric care is considered not medically necessary when the above criteria are not met.

 

Partial Hospitalization Program (PHP)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Diagnosis that is consistent with symptoms and the primary focus of treatment is partial hospitalization program (PHP) psychiatric care.

Severity of Illness (SI)
Must have all of the following  to qualify:

  1. Behavioral Health Condition, with mental health signs and symptoms: The member exhibits serious or disabling symptoms related to an acute mental health condition, or exacerbation of a severe and persistent mental disorder, or severe and persistent symptoms and impairments that have not improved or cannot be adequately addressed in a less intensive level of care; AND
  2. Level of Functioning: Marked impairments in multiple areas of his/her daily life are evident. This may include marked impairments that preclude adequate functioning in areas such as self-care, or other more specific role expectations such as bill paying, working, cleaning, problem solving, decision-making, contacting supports, taking care of others, addressing safety issues, medication compliance, or managing time in a meaningful way; AND
  3. Risk/Dangerousness: The member is not imminently dangerous to self or others and is able to exercise adequate control over his/her behavior to function outside of 24 hour custodial care. However, the member may exhibit some identifiable risk for harm to self or others yet is able to develop and practice a safety plan with the structured intensive support of PHP treatment; AND
  4. Social Support System: The member is or can be connected with a community-based network, which supports them within their home environment. The member may present with impaired ability to access or use caretaker, family or community support. In some cases a socially isolated person with serious debilitation symptoms may benefit. In other cases, a member from a trouble family may benefit as well. Minimal ability to set goals to work toward the development of social support is often a requirement for participation. In some cases, removal from a given residence or placement in a residential treatment setting may be a precondition for treatment; AND
  5. Readiness For Change: The presence of significant denial or pre-contemplation regarding change may often be anticipate due to the acute circumstances surrounding an admission. The member must however have the capacity for minimum engagement in the identification of goals for treatment, and willingness to try to participate actively in relevant components of the program. Initially, due to mental health and substance use disorder symptoms, the member may only be able to agree to begin treatment, and may require close monitoring, support and encouragement to achieve and sustain active and ongoing participation; AND
  6. Level of Care Rationale:
    1. The member has relapsed or failed to make significant clinical gains in a less intensive level of care; or
    2. Less intensive levels of care are judged insufficient to provide the treatment necessary; or
    3. The member is ready for discharge from an inpatient setting, but is judged to be in continued need of ongoing intensive therapeutic interventions, daily monitoring, and support that cannot be provided in a less intensive level of care.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Multidisciplinary treatment provided at least six hours a day. The frequency of attendance per week may vary according to clinical needs and progress, but should probably start four to five times a week; AND
  2. All services must consist of active treatment that specifically addresses the presenting problems of the members served and realistic goals that can be accomplished within the duration of treatment. Examples of active treatment include: group psychotherapy, psycho-educational (theme-specific) groups, skills training, expressive/activity therapies, medication evaluation/management, individual and family therapy; AND
  3. Involvement of the family, significant others and/or peers (as available and with signed consent) should be addressed in the mission and reflected in the program services offered; AND
  4. Programs operate under the direction of a physician and a program leader. The physician provides supervision of the clinical needs of the members enrolled in the program; the program leader is responsible for the overall clinical and administrative operations of the program; AND
  5. Staff members must possess appropriate academic degrees, licensure, or certification as well as experience with the particular populations treated as defined by program function and applicable state regulations. Core clinical staff members may include: psychiatrists, psychologists, social workers, counselors, addiction counselors, medical and nursing personnel. Occupational, recreational and creative arts therapists may also provide services. Paraprofessionals, non-degreed individuals, students and interns may be included; AND
  6. Coordination of care with other clinicians providing treatment to the member, such as the outpatient psychiatrist, therapist, and the member's PCP, and where indicated, clinicians providing treatment to other family members is documented; AND
  7. Physicians should have face to face contact on admission for an evaluation and thereafter as clinically indicated, at least one time a week. Clearly delineated procedures must be present for detoxification, withdrawal and other medical needs. Coordination of care with the member's primary care provider will take place in any situation where there are medical comorbidities. Physicians need to be available for consultation with other staff and for face to face evaluations with members during program hours or by telephone outside of program hours to be available 24 hours a day, seven days a week; AND
  8. A member of the clinical staff serves in a case management capacity to coordinate the member's treatment within the program who will work consistently with the member (and family as indicated) and follow the course of clinical treatment from admission through discharge; AND
  9. A clinical record is to be maintained for each member admitted. This has to include the following elements: initial assessment, physician orders and certification of need for this level of care, psychiatric assessment, treatment plan addressing only the needs which are of such severity that the intensity of PHP is needed with clear goals which are achievable within the timeframe of the program, medication management, progress notes and a discharge summary; AND
  10. Discharge planning begins at the time of admission with the identification of specific discharge criteria.

Continued Stay Criteria (CS)
Must have all of the following to qualify:

  1. Successful engagement in the clinical process; AND
  2. Active attendance and participation; AND
  3. Capacity to respond successfully to therapeutic interventions.
    AND

Must also have one or more of the following to qualify:

  1. Symptoms continue to impair multiple areas of daily functioning; OR
  2. Impaired judgment, awareness, and skill deficits place one at a significant risk for further functional deterioration; OR
  3. Member displays an inability to cope with significant crises or stressors and/or otherwise lacks the necessary skills to cope with marked symptoms; OR
  4. There is a continued significant risk for harm to self or others; OR
  5. Poor insight, skills, judgment, and /or awareness inhibits their return to critical baseline functioning.
    AND
    Must also have one or more of the following to qualify:
  6. Continued need for medication monitoring and intervention; OR
  7. Capacity to make progress in the development of coping skills to meet baseline functional needs; OR
  8. Need for support and guidance in handling a major life crisis; OR
  9. Continued need for managing risk accompanied by capacity to follow a safety plan; OR
  10. A commitment to developing and following through on a recovery oriented discharge plan.

May need to continue in PHP instead of IOP if three or more of these are present:

  1. Daily medication and overall symptom monitoring is needed.
  2. Immediate behavioral activation and monitoring is needed.
  3. Potential for self-harm is significant and requires daily observation and safety planning.
  4. Coping skill deficits are severe and require daily reinforcement.
  5. A crisis situation is present and requires daily monitoring.
  6. Family situation is volatile and requires daily observation and client instruction and support.
  7. Mood lability is extreme with potential to create destructive relationship or environmental consequences.
  8. Hopelessness or isolation is a dominant feature of clinical presentation with minimal current supports.
  9. Daily substance use monitoring is needed.
  10. Need for rapid improvement to return to necessary role expectations is present.

Not Medically Necessary:

Partial hospitalization program is considered not medically necessary when the above criteria are not met.

 

Intensive Structured Outpatient Program (IOP)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM or ICD Diagnosis that is consistent with symptoms and the primary focus of treatment is intensive structured outpatient program (IOP) psychiatric care.

Severity of Illness (SI)
Must have all of the following to qualify:

  1. The presence of moderate symptoms of a serious psychiatric diagnosis; AND
  2. Significant impairment in one or more spheres of personal functioning; AND
  3. The clear potential to regress further without specific IOP services; AND
  4. The need for direct monitoring less than daily but more than weekly; AND
  5. Specific Deficits that are directly related to services rendered; AND
  6. Significant variability in day to day capacity to cope with life situations.

A PHP may be appropriate in lieu of an IOP if three or more of these are present:

  1. Daily medication and overall symptom monitoring is needed.
  2. Immediate behavioral activation and monitoring is needed.
  3. Potential for self-harm is significant and requires daily observation and safety planning.
  4. Coping skill deficits are severe and require daily reinforcement.
  5. A crisis situation is present and requires daily monitoring.
  6. Family situation is volatile and requires daily observation and client instruction and support.
  7. Mood lability is extreme with potential to create destructive relationship or environmental consequences.
  8. Hopelessness or isolation is a dominant feature of clinical presentation with minimal current supports.
  9. Daily substance use monitoring is needed.
  10. Need for rapid improvement to return to necessary role expectations is present.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. Treatment services offered at least three treatment hours per day at least three times per week. With symptom improvement, a gradual decrease in services per week may occur to help plan for successful discharge and greater independent functioning. In some cases an evidence-based, time limited treatment protocol is provided for a given condition which may include a given number of sessions over several weeks; AND
  2. A comprehensive clinical assessment is done on admission that includes cognition/mental status, emotional/psychological function, activities of daily living, historical data (including social, medical and occupational histories), cultural issues, spirituality and medical screening. The treatment plan will be updated and individualized following previous treatment either from a higher or lower level of care; AND
  3. All services must consist of active treatment that specifically addresses the presenting problems of the members served and realistic goals that can be accomplished within the duration of treatment. Examples of active treatment include: group psychotherapy, psycho-educational (theme-specific) groups, skills training, expressive/activity therapies, medication evaluation/management, individual and family therapy. For children and adolescents, family therapy should be provided at least one time each week, unless clinically contraindicated; AND
  4. Group therapy is individualized to meet the member's needs, based on specific clinical needs or functional level; AND
  5. Staff members must possess appropriate academic degrees, licensure, or certification as well as experience with the particular populations treated as defined by program function and applicable state regulations; AND
  6. Coordination of care with other clinicians providing treatment to the member, such as the outpatient psychiatrist, therapist, and the member's PCP, and where indicated, clinicians providing treatment to other family members is documented; AND
  7. A clinical record is to be maintained for each member admitted. This has to include the following elements: initial assessment, physician orders and certification of need for this level of care, psychiatric assessment, treatment plan addressing only the needs which are of such severity that the intensity of IOP is needed with clear goals which are achievable within the timeframe of the program, medication management, progress toes and a discharge summary; AND
  8. A psychiatric evaluation by a physician should be done by the third day of attendance (unless stepping down from a higher level of care) and thereafter as needed.

Continued Stay Criteria (CS)
Must have all of the following to qualify:

  1. Symptoms are moderate and continue to impair daily functioning; AND
  2. Restoration of the level of functioning prior to development of the illness may not be possible, but enhancement of skills to cope with and prevent further deterioration is necessary; AND
  3. The member does not have a high likelihood of relapse to severity of symptoms that would require treatment at an inpatient or partial hospital program level of care; AND
  4. Stability cannot be maintained with regular outpatient treatment.

Not Medically Necessary:

Intensive structured outpatient program is considered not medically necessary when the above criteria are not met.

 

Inpatient/Outpatient Electroconvulsive Therapy (ECT)

Medically Necessary:

To qualify, member's symptoms or condition must meet the diagnostic criteria for a DSM Diagnosis of Major Depression, Bipolar Disorder, Mood Disorder, Severe Parkinson's Disease, Organic Catatonia, Schizoaffective Disorder or Schizophrenia and symptoms to confirm the diagnosis for inpatient/outpatient ECT treatment.

Severity of Illness (SI)
Must meet criteria 1 and either 2 or 3:

  1. Must have one of the following:
    1. History of a poor response to several trials of antidepressants in adequate doses for a sufficient time; or
    2. History of a good response to ECT during an earlier episode of illness; or
    3. Need for a rapid response due to the potentially life threatening nature of the member's illness; or
    4. Adverse effects with medication which are deemed to be less likely and/or severe with ECT; and
  2. For outpatient ECT, member must have adequate social and environmental support to maintain effective and safe treatment on an outpatient basis; OR
  3. For inpatient ECT, member must meet Severity of Illness (SI) Criteria for psychiatric adult/adolescent/child inpatient.

Intensity of Service (IS)
Must have all the following to qualify:

  1. History and physical completed within the 30 days prior to treatment and updated as needed; AND
  2. The qualified physician performing the ECT procedure must do a procedure note for each ECT treatment; AND
  3. The qualified physician performing the ECT and the member's attending physician must confer regularly regarding the member's progress; AND
  4. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans; AND
  5. The number and frequency of treatments requested are appropriate to the member's clinical condition and response; AND
  6. For ECT being done in an inpatient setting, Intensity of Service (IS) Criteria must be met for Adult Psychiatric Inpatient or outpatient ECT not available.

Continued Stay Criteria (CS)
Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress after the expected minimum number of treatments usually needed (based on the diagnosis) is being documented and maximal benefit has not yet been achieved.

Not Medically Necessary:

Inpatient/Outpatient Electroconvulsive Therapy (ECT) is considered not medically necessary when the above criteria are not met.

 

Outpatient Treatment

Medically Necessary:

Interventions will focus on the presenting symptoms and complaints that have led to a decrease in the member's usual level of functioning.

To qualify, the symptoms must meet the diagnostic criteria for a diagnosis from Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) for psychiatric outpatient treatment.

Severity of Illness (SI)
All of the following must be present:

  1. Specific symptoms or disturbances of mood and/or behavior are present, with functional impairment, which are consistent with the DSM/ICD diagnosis listed, and these disturbances/symptoms are likely to improve with treatment; AND
  2. The member demonstrates motivation for treatment and is capable of benefiting from the treatment approach planned.

Intensity of Service (IS)
All of the following must be present:

  1. Treatment goals target resolution of specific symptoms or stabilization of mood and/or behavior consistent with the DSM/ICD diagnoses listed and also target specific domains of functional impairment; AND
  2. Medication is being used for conditions where indicated, and if not, documentation of the reason and treatment interventions addressing the omission of this treatment; AND
  3. If substance abuse/dependence is a diagnosis or indicated to be present, a substance use evaluation has been performed when appropriate and treatment is being provided; AND
  4. Community/natural supports and resources are identified and utilized or skills to develop community/natural supports is  a treatment goal, including school/work interventions, self-help or diagnosis specific support groups, spiritual/religious, and community recreational activities; AND
  5. Coordination of care with other clinicians providing care to the member or family members, including psychiatrist/therapist and primary care physician (PCP) is documented; AND
  6. For children/adolescents, family participation in treatment or family therapy is documented unless contraindicated with documentation of the reason; AND
  7. Treatment is not duplicative of services being provided by another clinician for the same reasons/diagnoses; AND
  8. Provider must be properly licensed to provide the treatment requested.

Continued Stay Criteria (CS)
Must continue to meet "SI/IS" Criteria and have the following qualify:

Frequency Criteria: for treatment that occurs more frequently than once per week (excluding Medication Management) must have all of the following to qualify:

  1. Either the member has been discharged from an inpatient, residential or PHP service and more frequent outpatient (OP) treatment is required as a transition for the purposes of stabilization while returning to the community or the member is in crisis as evidenced by suicidal ideation or high risk behavior that is manageable on an OP basis, or an unexpected increase in symptoms and/or behaviors or worsening in mood where the treatment goals are focused on stabilization of the crisis; AND
  2. The symptoms/behaviors or mood that represent the crisis can be stabilized with more frequent treatment as evidenced by urgent psychiatric contact and medication changes if indicated and reports of progress with resolving the crisis; AND
  3. The condition has not stabilized to the point where less frequent treatment which targets less critical symptoms/behaviors is equally appropriate.

    Frequency Criteria: for treatment up to once per week (excluding Medication Management) must have all of the following to qualify:
  4. Progress with the targeted symptoms/behaviors and/or mood is documented at the expected pace given the presence of medical/physical conditions, stressors and level of support, as evidenced by adherence with treatment, improving severity of symptoms and functional impairment and continued progress is expected for the targeted symptoms and behaviors or mood with the treatment approaches being used; AND
  5. If progress is not documented, either diagnosis has been re-evaluated and changed if appropriate, medication has been re-evaluated and changed if indicated, or the treatment approach has been re-evaluated and changed if appropriate to include a diagnosis specific therapy, family therapy or new treatment goals/targets; AND
  6. The goals of treatment are not primarily for providing support, targets are not primarily symptoms/behaviors which are either chronic and not likely to improve with the type of treatment being used, or primarily self-improvement; AND
  7. Symptoms and/or functional impairment of at least a moderate degree as evidenced by report of specific domains are still present related to the DSM/ICD diagnoses listed and likely to improve with continued treatment; AND
  8. The member is allowing coordination of care with other providers and evidence of this is documented, and is involving family members where indicated; for children/adolescents, the family is participating in treatment and adhering to recommendations; AND
  9. The condition has not stabilized to the point where maintenance treatment is appropriate, where sustained improvement is not likely and the purpose of continued treatment is to prevent relapse or maintain previous achieved progress.

    Frequency Criteria: for treatment every other week, (excluding Medication Management) must have all of the following to qualify:
  10. Symptoms/behaviors or mood disturbances persist consistent with the DSM/ICD diagnoses listed which have not remitted as shown by moderate to severe symptoms and functional impairment, that require maintenance treatment to ensure that previously achieved progress in treatment is sustained and where relapse or deterioration is likely without this degree of continued treatment; AND
  11. Maintenance treatment cannot be provided by medication management alone or medication treatment is only partially effective and intermittent therapy support is required in addition to medication maintenance treatment. When treatment frequency is being transitioned from once weekly (or more) to once monthly (or less), a reduction in frequency to maintenance treatment should be done with a brief period of transition to maintain stability.

    Frequency Criteria: for treatment once monthly, (excluding Medication Management) must have all of the following to qualify:
  12.  Symptoms/behaviors or mood disturbances persist consistent with the DSM/ICD diagnoses listed that require maintenance treatment to ensure that previously achieved progress in treatment is sustained and where relapse or deterioration is likely without this degree of continued treatment; AND
  13. Maintenance treatment cannot be provided by medication management alone or medication treatment is only partially effective and intermittent therapy support is required in addition to medication maintenance treatment.

Not Medically Necessary:

Psychiatric outpatient treatment is considered not medically necessary when the above criteria are not met.

Medication Management

Medically Necessary:

Medication management is provided for members who require a medical evaluation and ongoing supervision and prescription of psychotropic medications.

Severity of Illness (SI)
Must have all of the following to qualify:

  1. Medical evaluation to determine whether there is a need for medication; AND
  2. Medical prescription of psychotropic drugs and on-going medication monitoring; AND
  3. Diagnoses from DSM or Psychiatric Diagnosis for ICD.

Intensity of Service (IS)
Must have all of the following to qualify:

  1. The physician meets with the member, face to face, on a scheduled basis;
    1. Acute members - The physician may see the member up to once or twice a week if the member is not yet stabilized on medication or is suffering from adverse side effects.
    2. Stabilized/chronic members - The physician typically sees the member monthly or at least quarterly (or less frequently when stable) when indicated, if the member's pharmacological plan is appropriate and the member does not experience complications from medication. Up to one year may be certified; AND
  2. A qualified physician, psychiatric nurse practitioner (or physician extender or independently licensed clinician as permitted by law or health plan benefits) as appropriate prescribes the medication; AND
  3. The physician or other prescriber collaborates with a psychotherapist (if there is one) and PCP as appropriate, when a prescription is initiated or changed. Coordination of care should occur at regular intervals and be documented; AND
  4. Adherence to documentation and treatment plan guidelines; AND
  5. Family involvement is a part of child/adolescent management unless clinically contraindicated; AND
  6. Substance use evaluation has been completed when appropriate.

Continued Stay Criteria (CS)
Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress is documented and the member is cooperative and motivated such that continued progress is expected, and if not then the treatment plan is being changed or if no further progress expected, then a maintenance plan is in effect.

Not Medically Necessary:

Medication management in psychiatric outpatient treatment is considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Note: The following list of procedure codes are examples only and may not represent all codes being used for psychiatric disorder treatments. Please contact the member's plan for applicable coding conventions as these may vary.

 
Electroconvulsive Therapy (ETC)
90870Electroconvulsive therapy (includes necessary monitoring)
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 For the following diagnoses, including but not limited to:
290.0-319Mental, behavioral and neurodevelopmental disorders
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 For the following diagnoses, including but not limited to:
F01.50-F99Mental, behavioral and neurodevelopmental disorders
 
Psychiatric Outpatient Treatment
CPT 
 For the following procedures when performed in the outpatient setting:
90832Psychotherapy, 30 minutes with patient and/or family member
90833Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service [add-on]
90834Psychotherapy, 45 minutes with patient and/or family member
90836Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service [add-on]
90837Psychotherapy, 60 minutes with patient and/or family member
90838Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service [add-on]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 For the following diagnoses, including but not limited to:
290.0-319Mental, behavioral and neurodevelopmental disorders
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 For the following diagnoses, including but not limited to:
F01.50-F99Mental, behavioral and neurodevelopmental disorders
 
Medication Management
90863Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services [add-on]
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 For the following diagnoses, including but not limited to:
290.0-319Mental, behavioral and neurodevelopmental disorders
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 For the following diagnoses, including but not limited to:
F01.50-F99Mental, behavioral and neurodevelopmental disorders
  
Discussion/General Information

Psychiatric disorders can include a wide range of mental health diagnoses. The illnesses are described in current diagnosis sources (DSM-5, ICD-9-CM). The type of service needed reflects the gravity and acuity of symptoms. Determining the appropriate level and place of treatment is important for potential safety of the member as well as addressing the concerns of family members and society. The criteria in this document capture problems that warrant each of the levels of care. In addition, the document informs about the types of services to be provided by any of the types of care and changes in condition that suggests treatment with less intense services.

Applied Behavioral Analysis (ABA) and other types of behavioral interventions often used for autism spectrum disorders (ASD's) are based on learning principles. These treatments can be distinguished from outpatient therapy described above because treatment such as ABA incorporates elements of learning such as teaching the affected individual to read or work math problems. In addition, these treatments include elements characteristic of speech therapy such as naming objects. Finally, at least some individuals with ASD's need extensive coaching on tasks related to personal care such as toileting as part of the treatment. Treatment with ABA and related therapies can be complemented with outpatient therapy as described above with treatment such as family therapy addressing depression and irritability exhibited by parents, siblings and other family members of an individual suffering from ASD or medication visits to manage medications.

Psychiatric treatment should not be primarily for the avoidance of incarceration of the member or to satisfy a programmatic length of stay (refers to a pre-determined number of days or visits for a program's length instead of an individualized determination of how long a member needs to be in that program). There should be a reasonable expectation that the member's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the member's illness.

It is noted that there is variation in the availability of services in different geographic and regional areas. If an indicated service is not available within a member's community at the level of service indicated by the criteria, authorization may be given for those services at the next highest available level.

In some geographical areas, state regulations allow non-physicians to treat members at inpatient facilities. In these documents, such non-physicians with prescriptive authority who are operating within the scope of their license may be substituted where the criteria specifies a physician.

Definitions

Acute Inpatient Hospitalization: Acute inpatient psychiatric hospitalization is defined as treatment in a hospital psychiatric unit that includes 24-hour nursing and daily active treatment under the direction of a psychiatrist and certified by The Joint Commission or the National Integrated Accreditation for Healthcare Organizations (NIAHO) as a hospital. Acute psychiatric treatment is appropriate in an inpatient setting when required to stabilize members who are in acute distress and return them to a level of functioning in which a lesser level of intense treatment can be provided. A need for acute inpatient care occurs when the member requires 24-hour nursing care, close observation, assessment, treatment and a structured therapeutic environment that is available only in an acute inpatient setting.

Residential Treatment: Residential treatment is defined as specialized treatment that occurs in a residential treatment center. Residential treatment is 24 hours per day and requires a minimum of one physician visit per week in a facility based setting. Wilderness programs are not considered residential treatment programs.

Partial Hospitalization: Partial hospitalization (sometimes called day treatment) is a structured, short-term treatment modality that offers nursing care and active treatment in a program that is operable at a minimum of six hours per day, five days per week. Members must attend a minimum of six hours per day when participating in a partial hospitalization program. Members are not cared for on a 24-hour per day basis, and typically leave the program each evening and/or weekends. Partial hospitalization treatment is provided by a multidisciplinary treatment team, which includes a psychiatrist. Partial hospitalization is an alternative to acute inpatient hospital care and offers intensive, coordinated, multidisciplinary clinical services for members that are able to function in the community at a minimally appropriate level and do not present an imminent potential for harm to themselves or others.

Intensive Outpatient Treatment: Intensive outpatient is a structured, short-term treatment modality that provides a combination of individual, group and family therapy. Intensive outpatient programs meet at least three times per week, providing a minimum of three hours of treatment per session. Intensive outpatient programs must be supervised by a licensed mental health professional. Intensive outpatient treatment is an alternative to inpatient or partial hospital care and offers intensive, coordinated, multidisciplinary services for members with an active psychiatric or substance related illness who are able to function in the community at a minimally appropriate level and present no imminent potential for harm to themselves or others.

Outpatient Treatment: Outpatient treatment is a level of care in which a mental health professional licensed to practice independently provides care to individuals in an outpatient setting, whether to the member individually, in family therapy, or in a group modality.

References

Peer Reviewed Publications:

  1. Frances A Docherty JP, Kahn DA. The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry. 1996; 5(Suppl 12A):1-88.
  2. McEvoy JP, Scheifler PL, Frances A. Treatment of schizophrenia 1999. The expert consensus guideline series. J Clin Psychiatry. 1999; 60 Suppl 11:3-80.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Child & Adolescent Psychiatry. Practice Parameters. Available at: http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters. Accessed on April 8, 2014.
  2. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on April 8, 2014.
  3. American Society of Addiction Medicine. Public Policy Statement on Co-occurring Addictive and Psychiatric Disorders. 2000. Available at: http://www.asam.org/docs/publicy-policy-statements/1co-occurring-disorders-12-00.pdf?sfvrsn=0. Accessed on May 8, 2014.
  4. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on April 8, 2014.
  5. Association for Ambulatory Behavioral Health Care. Standards and Guidelines for Partial Hospitalization Programs. 5th Ed. Portsmouth, VA. 2012.
  6. Depression in Primary Care: Detection and Diagnosis. Volume 1. Detection and Diagnosis Clinical Guideline Number 5. AHCPR Publication No. 93-0550: April 1993.
  7. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA. 2013. Available at: http://dsm.psychiatryonline.org/book.aspx?bookid=556. Accessed on April 24, 2014.
  8. Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
  9. Weiner RD. Practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (A task force report of the American Psychiatric Association). 2nd ed. Arlington: American Psychiatric Publishing. 2001.
Index

Electroconvulsive Therapy (ECT)
Independent Practice Level
Intensive Structured outpatient Program (IOP)
Medication Management
Partial Hospitalization Program (PHP)
Residential Treatment Center (RTC)

History

Status

Date

Action

Revised08/14/2014Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised08/08/2014Behavioral Health Subcommittee review. Multiple additions to Medical Necessity Criteria. Updated Description/Scope, Discussion/General Information, References and Index. Addition of Psychiatric outpatient treatment and Medication management criteria from CG-BEH-06 (Psychiatric Outpatient Treatment) added to the scope of this document. Removal of reference to global assessment of functioning scores from Medical Necessity Criteria.
Revised02/13/2014MPTAC review.
Revised02/07/2014Behavioral Health Subcommittee review. Removed indications of Axis from Clinical Indications.
New08/08/2013MPTAC review.
New07/26/2013Behavioral Health Subcommittee review. Initial document development. Clarification to Clinical Indications Partial Hospitalization Program and Intensity of Service. Updated References. The Behavioral Health Medical Necessity Criteria effective January 1, 2013 was split apart into specific subject matter clinical UM guidelines.