The medical necessity criteria outlined in this guideline for each level of care relating to psychiatric outpatient treatment includes three categories; Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria includes descriptions of the Covered Individual'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 outpatient treatment (including treatment provided by a clinician licensed at the independent practice level) and medication management.
Please see the following related document(s) for additional information:
Interventions will focus on the presenting symptoms and complaints that have led to a decrease in the Covered Individual'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 covered by the Covered Individual's plan.
Severity of Illness (SI)
All of the following must be present:
- 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
- The Covered Individual 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:
- 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
- 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
- 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
- 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
- Coordination of care with other clinicians providing care to the Covered Individual or family members, including psychiatrist/therapist and primary care physician (PCP) is documented; AND
- For children/adolescents, family participation in treatment or family therapy is documented unless contraindicated with documentation of the reason; AND
- Treatment is not duplicative of services being provided by another clinician for the same reasons/diagnoses; AND
- 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 (1 - 3) to qualify:
- Either the Covered Individual has been discharged from an inpatient, residential or partial hospitalization program (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 Covered Individual 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
- 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
- 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 (4 – 9) to qualify:
- 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 global assessment of functioning (GAF) scores, and continued progress is expected for the targeted symptoms and behaviors or mood with the treatment approaches being used; AND
- 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
- 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
- Symptoms and/or functional impairment of at least a moderate degree as evidenced by report of specific domains and/or GAF score less than or equal to 60 are still present related to the DSM/ICD diagnoses listed and likely to improve with continued treatment; AND
- The Covered Individual 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
- 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 (10 – 11) to qualify:
- 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
- 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 (12 – 13) to qualify:
- 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
- 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 is provided for Covered Individuals 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:
- Medical evaluation to determine whether there is a need for medication; AND
- Medical prescription of psychotropic drugs and on-going medication monitoring; AND
- Diagnoses from DSM or Psychiatric Diagnosis for ICD.
Intensity of Service (IS)
Must have all of the following to qualify:
- The physician meets with the Covered Individual, face to face, on a scheduled basis;
- Acute Covered Individuals - The physician may see the Covered Individual up to once or twice a week if the Covered Individual is not yet stabilized on medication or is suffering from adverse side effects.
- Stabilized/chronic Covered Individuals – The physician typically sees the Covered Individual monthly or at least quarterly (or less frequently when stable) when indicated, if the Covered Individual's pharmacological plan is appropriate and the Covered Individual does not experience complications from medication. Up to one year may be certified; AND
- 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
- 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
- Adherence to documentation and treatment plan guidelines; AND
- Family involvement is a part of child/adolescent management unless clinically contraindicated; AND
- 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:
- Progress is documented and the Covered Individual 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.
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.
| ||For the following procedures when performed in the outpatient setting:|
|90832||Psychotherapy, 30 minutes with patient and/or family member|
|90833||Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service [add-on]|
|90834||Psychotherapy, 45 minutes with patient and/or family member|
|90836||Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service [add-on]|
|90837||Psychotherapy, 60 minutes with patient and/or family member|
|90838||Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service [add-on]|
|90863||Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services [add-on]|
| || |
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|290.0-319||Mental, behavioral and neurodevelopmental disorders|
| || |
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2014]|
Mental, behavioral and neurodevelopmental disorders
Psychiatric outpatient treatment should not be primarily for the avoidance of incarceration of the Covered Individual or to satisfy a programmatic length of stay (refers to a pre-determine 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 Covered Individual's illness, condition, or level of functioning will be stabilized, improved, or maintained through treatment known to be effective for the Covered Individual'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 Covered Individual'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 Covered Individuals at inpatient facilities. In these guidelines, such non-physicians with prescriptive authority who are operating within the scope of their license may be substituted where the criteria specifies a physician.
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 Covered Individuals 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 Covered Individual 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 (6) hours per day, five (5) days per week. Covered Individuals must attend a minimum of 6 hours per day when participating in a partial hospitalization program. Covered Individuals 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 Covered Individuals 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 (3) 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 Covered Individuals 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 Covered Individual individually, in family therapy, or in a group modality.
Peer Reviewed Publications:
- Kahn, DA, Carpenter D, Docherty JP, Frances A. (1996): The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry, 57 (Suppl 12A).
- 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:
- 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 January 13, 2014.
- American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on January 13, 2014.
- American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on January 13, 2014.
- Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.
- Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 07-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
- Depression in Primary Care: Detection and Diagnosis. Volume 1. Detection and Diagnosis Clinical Guideline Number 5. AHCPR Publication No. 93-0550: April 1993.
- Fishman MJ, Shulman GD, Mee-Lee D, et al. ASAM patient placement criteria: supplement on pharmacotherapies for alcohol use disorders. 1st ed. Philadelphia: Lippincott Williams & Wilkins. 2010.
- Hoffman NG, Mee-Lee D, Halikas JA. Patient placement criteria for the treatment of psychoactive substance use disorders. Chevy Chase: American Society of Addiction Medicine. 2001.
- Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
- Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
- Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. Intensive outpatient treatment for alcohol and other drug abuse. 1994. DHHS Publication No. (SMA) 94B2077.
- Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
- Weiner RD. Manual of psychiatric quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992. Electroconvulsive therapy guidelines and criteria.
- 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.
Independent practice level
|Revised||02/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review.|
|Revised||02/07/2014||Behavioral Health Subcommittee review. Removed indications of Axis I and II from Clinical Indications.|
|New||07/26/2013||Behavioral Health Subcommittee review. Initial document development. Updated References. Added Not Medically Necessary Statements. The Behavioral Health Medical Necessity Criteria effective January 1, 2013 was split apart into specific subject matter clinical UM guidelines.|