Clinical UM Guideline


Subject:  Psychiatric Disorder Treatment
Guideline #:  CG-BEH-03Current Effective Date:  02/17/2014
Status:RevisedLast Review Date:  02/13/2014

Description

The medical necessity criteria outlined in this guideline 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 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 disorder treatment for:

Please see the following related document(s) for additional information:

Clinical Indications

Acute Inpatient

Medically Necessary:

To qualify, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have one (1) 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 Covered Individual is unable to care for him or herself, and therefore an imminent danger to themselves or others 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
  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 (7) 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 (1) to two (2) 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 Covered Individual's primary care physician (PCP), providing treatment to the Covered Individual, 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 Covered Individual is cooperating with treatment; if the Covered Individual 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 Covered Individual'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, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have all of the following to qualify:

  1. The Covered Individual 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 Covered Individual 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 Covered Individual 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 (8) 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 Covered Individual's PCP, providing treatment to the Covered Individual, 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 (8) 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 Covered Individual will reside; AND
  12. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered Individuals 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 Covered Individual 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, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must have 1-4, or 1-5 if coming directly from a higher level of care to qualify:

  1. Symptoms or behaviors that could be treated must be present that would likely progress to a level of dangerousness or failure of self care that would require Inpatient treatment without a structured treatment setting of at least six (6) hours duration a day; AND
  2. Significant functional impairment is present as evidenced by inability to work or attend school, impaired self care and significant conflicts with the support environment; AND
  3. The Covered Individual does not also meet criteria for IOP; AND
  4. The Covered Individual's social environment may not be supportive but is adequate for the individual to cope and PHP could help stabilize the social environment to an extent that would allow continued treatment at a lower level of care;
    If coming directly from a higher level of care, must also have:
  5. Covered Individual has been discharged from a higher level of care and continues to require an intensive, structured treatment program to maintain progress and stability during a period of transition to a lower level of care.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Multidisciplinary treatment provided at least six (6) hours a day. The frequency of attendance per week may vary according to clinical needs and progress. Normally, the goals of treatment or maximum treatment benefit at this level of care can be achieved within ten (10) days of partial hospitalization program treatment; AND
  2. Multidisciplinary assessment with a treatment plan which addresses psychological, social, medical, and substance abuse needs; AND
  3. Evaluation by a qualified physician done by the second day of attendance and at least weekly visits thereafter; AND
  4. Monitoring of psychotropic medications including compliance as appropriate and documented rationale if no medication is prescribed; AND
  5. Family assessment and therapy by a licensed behavioral health provider when appropriate. For children and adolescents, at least one (1) to two (2) times each week, unless clinically contraindicated; AND
  6. Individual therapy by a licensed provider at least weekly; AND
  7. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  8. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans; AND
  9. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered Individuals will be prepared to receive the majority of their treatment in a community setting; AND
  10. The Covered Individual resides in a community setting while receiving partial hospitalization services and is not in a 24-hour residential treatment setting; AND
  11. 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.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress in treatment is being documented and the Covered Individual's participation and cooperation with treatment is consistent with PHP having continued benefit; if no progress then the treatment plan is being re-evaluated and amended in a timely and medically appropriate manner that is likely to be of benefit.

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, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

Severity of Illness (SI)

Must meet either 1 or 2, and 3 to qualify:

  1. Serious symptoms or serious impairment in social, occupational or family functioning that requires intensive and structured intervention; OR
  2. A well-defined clinical rationale is documented that explains why Covered Individual would not be a reasonable candidate for outpatient therapy combined with community supports; AND
  3. The Covered Individual has adequate cognitive abilities, to assume responsibility for behavioral change, and is capable of developing skills to cope with their symptoms.

Intensity of Service (IS)

Must have all of the following to qualify:

  1. Provide multidisciplinary program of at least three (3) treatment hours per day at least three times per week; the frequency may be decreased as clinically indicated; AND
  2. Multidisciplinary assessment with an individualized treatment plan which addresses psychological, social, medical, cognitive, and substance abuse needs. This should include coordination of care with Covered Individual's outpatient providers; AND
  3. To be seen by a qualified physician by the third day of attendance (unless stepping down from a higher level of care); AND
  4. Monitoring of psychotropic medications including compliance as appropriate and documented rationale if no medication is prescribed. Medication management external to program is reflected in program documentation; AND
  5. Family assessment and therapy by a licensed behavioral health provider. For children and adolescents, at least one time each week, unless clinically contraindicated; AND
  6. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individual's PCP, providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is documented; AND
  7. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans; AND
  8. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered Individuals will be prepared to receive the majority of their treatment in a community setting; AND
  9. The Covered Individual resides in a community setting while receiving intensive outpatient program services and is not in a 24-hour residential treatment setting.

Continued Stay Criteria (CS)

Must continue to meet "SI/IS" Criteria and have the following to qualify:

  1. Progress in treatment is being documented and the Covered Individual's participation and cooperation with treatment is consistent with IOP having continued benefit; if no progress then the treatment plan is being re-evaluated and amended in a timely and medically appropriate manner that is likely to be of benefit.

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, Covered Individual'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. All services must meet the definition of medical necessity in the Covered Individual's plan document.

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 Covered Individual'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, Covered Individual must have adequate social and environmental support to maintain effective and safe treatment on an outpatient basis; OR
  3. For inpatient ECT, Covered Individual 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 Covered Individual's attending physician must confer regularly regarding the Covered Individual'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 Covered Individual'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.

Coding

Coding edits for medical necessity review are not implemented for this guideline.  Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions.  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.

Discussion/General Information

Psychiatric disorder 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-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 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.

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 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 six (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.

References

Peer Reviewed Publications:

  1. Kahn, DA, Carpenter D, Docherty JP, Frances A. (1996): The expert consensus guideline series: treatment of bipolar disorder. J Clin Psychiatry, 57 (Suppl 12A).
  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 January 13, 2014.
  2. American Psychiatric Association. Clinical Practice Guidelines. Available at: http://www.psych.org/practice/clinical-practice-guidelines. Accessed on January 13, 2014.
  3. American Society of Addiction Medicine Treatment. Available at: http://www.asam.org/research-treatment/treatment. Accessed on January 13, 2014.
  4. 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.
  5. 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.
  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. 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.
  8. 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.
  9. Manual of Psychiatric Peer Review (1974). American Psychiatric Association.
  10. Mattson M. Manual of psychiatric quality assurance: American Psychiatric Association committee on quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992.
  11. 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.
  12. Treatment of Major Depression. Volume 2. Treatment of Major Depression Clinical Practice Guideline Number 5. AHCPR Publication No. 93-0551: April 1993.
  13. Weiner RD. Manual of psychiatric quality assurance. 1st ed. Arlington: American Psychiatric Publishing. 1992. Electroconvulsive therapy guidelines and criteria.
  14. 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)
Intensive Structured outpatient Program (IOP)
Partial Hospitalization Program (PHP)
Residential Treatment Center (RTC)

History

Status

Date

Action

Revised02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) 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.