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COVERAGE
DETERMINATION
GUIDELINE
OPTUM™
By United Behavioral Health
Treatment of Major Depressive Disorder and
Dysthymic Disorder
Guideline Number: BHCDG042014
Product:
Effective Date: August, 2010
2001 Generic UnitedHealthcare COC/SPD
Revision Date: April, 2014
2007 Generic UnitedHealthcare COC/SPD
2009 Generic UnitedHealthcare COC/SPD
2011 Generic UnitedHealthcare COC/SPD
Table of Contents:
Instructions for Use……………………….2
Related Coverage Determination
Guidelines:
Key Points………………………………....2
Custodial Care and Inpatient Services
Benefits…………………………………….2
Electroconvulsive Therapy (ECT)
Clinical Best Practices…………………....5
Transcranial Magnetic Stimulation
Level of Care Criteria…………………....19
Additional Resources…………………....15
Definitions…………………………………20
References……………………………......21
Coding…………………………………......22
History……………………………………...24
Related Medical Policies:
Level of Care Guidelines
American Academy of Child and Adolescent
Psychiatry Practice Parameter for the
Assessment and Treatment of Children and
Adolescents with Depressive Disorders,
2007
American Psychiatric Association, Practice
Guideline for the Treatment of Patients with
Major Depressive Disorder, 2010
American Psychiatric Association, Practice
Guideline for the Assessment and
Treatment of Patients with Suicidal
Behaviors, 2003
Treatment of Major Depressive Disorder (MDD) and Dysthymic Disorder
Coverage Determination Guideline
Confidential and Proprietary, © Optum 2014
Optum is a brand used by United Behavioral Health and its affiliates.
Page 1 of 24
INSTRUCTIONS FOR USE
This Coverage Determination Guideline provides assistance in interpreting behavioral health
benefit plans that are managed by Optum. This Coverage Determination Guideline is also
applicable to behavioral health benefit plans managed by Pacificare Behavioral Health and U.S.
Behavioral Health Plan, California (doing business as Optum California (“Optum-CA”). When
deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee’s
document (e.g., Certificates of Coverage (COCs), Schedules of Benefits (SOBs), or Summary
Plan Descriptions (SPDs) may differ greatly from the standard benefit plans upon which this
guideline is based. In the event that the requested service or procedure is limited or excluded
from the benefit, is defined differently, or there is otherwise a conflict between this document and
the COC/SPD, the enrollee's specific benefit document supersedes these guidelines.
All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements
that supersede the COC/SPD and the plan benefit coverage prior to use of this guideline. Other
coverage determination guidelines and clinical guideline may apply.
Optum reserves the right, in its sole discretion, to modify its coverage determination guidelines
and clinical guidelines as necessary.
While this Coverage Determination Guideline does reflect Optum’s understanding of current best
practices in care, it does not constitute medical advice.
Key Points
x
Major Depressive Disorder (MDD) is a form of Mood Disorder whose essential feature is the
presence of a Major Depressive episode of at least two weeks in duration during which there
is either depressed mood or the loss of interest or pleasure in nearly all activities (Diagnostic
th
and Statistical Manual of Mental Disorders, 4 ed.; DSM-IV-TR; American Psychiatric
Association (DSM-IV-TR), 2000).
x
Dysthymic Disorder is a form of Mood Disorder whose essential feature is a chronically
depressed mood that occurs for most of the day more days than not for at least 2 years
(DSM-IV-TR, 2000).
x
Benefits are available for covered services that are not otherwise limited or excluded.
x
Pre-notification is required for inpatient, residential treatment, partial hospital/day treatment
programs, intensive outpatient programs, and home-based outpatient treatment.
x
Choice of the most appropriate treatment setting should take into consideration if (Optum
Level of Care Guidelines (LOCGs), 2014):
x
o
The proposed level of care is available.
o
The proposed level of care is structured and intensive enough to safely and
adequately treat the member’s presenting problem and support the member’s
recovery/resiliency.
o
There is a reasonable expectation that the member’s condition will improve with the
implementation of evidence-based treatments.
Services should be consistent with evidence-based interventions and clinical best practices
as described in Part III, and should be of sufficient intensity to address the member's needs
(UnitedHealth Care, Certificate of Coverage (COC), 2007, 2009 & 2011).
PART I: BENEFITS
Before using this guideline, please check enrollee’s specific plan document and
any federal or state mandates, if applicable.
Page 2 of 24
Benefits
Benefits include the following services:
x
Diagnostic evaluation and assessment
x
Treatment planning
x
Referral services
x
Medication management
x
Individual, family, therapeutic group and provider-based case
management services
x
Crisis intervention
Covered Services
Covered Health Service(s) – 2001
Those health services provided for the purpose of preventing, diagnosing or
treating a sickness, injury, mental illness, substance abuse, or their
symptoms.
A Covered Health Service is a health care service or supply described in
Section 1: What's Covered--Benefits as a Covered Health Service, which is
not excluded under Section 2: What's Not Covered--Exclusions.
Covered Health Service(s) – 2007, 2009 and 2011
Those health services, including services, supplies, or Pharmaceutical
Products, which we determine to be all of the following:
x
Provided for the purpose of preventing, diagnosing or treating a
sickness, injury, mental illness, substance abuse, or their symptoms.
x
Consistent with nationally recognized scientific evidence as available,
and prevailing medical standards and clinical guidelines as described
below.
x
Not provided for the convenience of the Covered Person, Physician,
facility or any other person.
x
Described in this Certificate of Coverage under Section 1: Covered
Health Services and in the Schedule of Benefits.
x
Not otherwise excluded in this Certificate of Coverage under Section 2:
Exclusions and Limitations.
In applying the above definition, "scientific evidence" and "prevailing medical
standards" shall have the following meanings:
x
"Scientific evidence" means the results of controlled clinical trials or
other studies published in peer-reviewed, medical literature generally
recognized by the relevant medical specialty community.
Page 3 of 24
x
"Prevailing medical standards and clinical guidelines" means nationally
recognized professional standards of care including, but not limited to,
national consensus statements, nationally recognized clinical
guidelines, and national specialty society guidelines.
Pre-Service Notification
Admissions to an inpatient, residential treatment center, partial hospital/day
treatment program, intensive outpatient, and home-based outpatient treatment
require pre-service notification. Notification of a scheduled admission must occur
at least five (5) business days before admission. Notification of an unscheduled
admission (including Emergency admissions) should occur as soon as is
reasonably possible. Benefits may be reduced if Optum is not notified of an
admission to these levels of care. Check the member’s specific benefit plan
document for the applicable penalty and provision for a grace period before
applying a penalty for failure to notify Optum as required.
Limitations and Exclusions
The requested service or procedure for the treatment of a mental health condition
must be reviewed against the language in the enrollee's benefit document. When
the requested service or procedure is limited or excluded from the enrollee’s
benefit document, or is otherwise defined differently, it is the terms of the
enrollee's benefit document that prevails.
Inconsistent or Inappropriate Services or Supplies – 2001, 2007, 2009 &
2011
Services or supplies for the diagnosis or treatment of Mental Illness that, in
the reasonable judgment of the Mental Health/Substance Use Disorder
Designee, are any of the following:
x
Not consistent with generally accepted standards of medical practice
for the treatment of such conditions.
x
Not consistent with services backed by credible research soundly
demonstrating that the services or supplies will have a measurable and
beneficial health outcome, and are therefore considered experimental.
x
Not consistent with the Mental Health/Substance Use Disorder
Designee’s level of care guidelines or best practice guidelines as
modified from time to time.
x
Not clinically appropriate for the member’s Mental Illness or condition
based on generally accepted standards of medical practice and
benchmarks.
Additional Information
The lack of a specific exclusion that excludes coverage for a service does not
imply that the service is covered.
Page 4 of 24
The following are examples of services that are inconsistent with the Level of
Care Guidelines and Best Practice Guidelines (not an all-inclusive list):
x
Services that deviate from the indications for coverage summarized
earlier in this document.
x
Admission to an inpatient, residential treatment, partial hospital/day
treatment program, intensive outpatient program, or home-based
outpatient treatment without evidence-based treatment of acute
symptoms.
x
Admission to an inpatient, residential treatment, partial hospital/day
treatment program, intensive outpatient program, or home-based
outpatient treatment for the sole purpose of awaiting placement in a
long-term facility.
x
Admission to an inpatient, residential treatment, partial hospital/day
treatment program, intensive outpatient program, or home-based
outpatient treatment that does not provide adequate nursing care and
monitoring, or physician coverage.
x
The use of psychological or neuropsychological testing when a
diagnostic or treatment planning question can be answered by means
of a standard interview and behavior rating scale assessment.
Please refer to the enrollee’s benefit document for ASO plans with benefit
language other than the generic benefit document language.
PART II: CLINICAL BEST PRACTICES
Evaluation and Treatment Planning
An evaluation is completed to identify the “why now” factors that precipitated the
need for service (e.g., changes in the member’s signs and symptoms,
psychosocial and environmental factors, or level of functioning) and supports the
choice of the most appropriate treatment setting and formulation of the treatment
plan (LOCGs, 2014). All of the following should be included as part of the
evaluation:
Standard Evaluation
The provider collects information from the member and other sources, and
completes an initial evaluation of the following (LOCGs, 2014):
x
The member’s chief complaint,
x
A description of the acute condition or exacerbation of a chronic
condition;
x
The “why now” factors;
x
The member’s psychiatric and medical histories including the histories
of substance use, abuse and trauma;
x
The member’s history of treatment;
Page 5 of 24
x
Psychosocial and environmental problems;
x
Mental status examination;
x
Physical examination (when appropriate);
x
Risk factors including those related to harm to self or others, as well as
risk stemming from co-occurring behavioral health or medical
conditions;
x
Assessment of the member’s use of coping strategies;
x
The member’s readiness for change;
x
The member’s Resilience factors;
x
The member’s instructions for treatment or appointment of an agent to
make decisions about mental health treatment; and
x
The member’s recovery and resiliency goals.
Evaluation of Depressive Symptoms
All of the following should be evaluated as part of the evaluation of Major
Depressive Disorder (American Psychiatric Association, Clinical Practice
Guideline, Major Depressive Disorder (APA Guideline), 2010):
x
The events leading up to the current episode of care
x
Baseline measurement of depressive symptoms with the use of one of
the following validated rating scales (O’Reardon, 2007):
o Beck Depression Scale (BDI),
o Hamilton Depression Rating Scale (HDRS),
o Montgomery-Asberg Depression Rating Scale (MADRS) or
o Patient Health Questionnaire (PHQ-9)
x
Current level of functioning
x
History of medication treatment trials for depression and response
x
The history of interventions targeting depression or co-occurring
conditions including psychosocial interventions, use of community
resources, and response to previous interventions
x
Side effects experienced from prescribed and over-the-counter
medications
x
Results of laboratory tests when indicated
x
The history of the onset and progression of symptoms
x
The member’s ability to make informed treatment decisions
x
The ability of the member’s family/caregiver to participate in the
member’s treatment
Page 6 of 24
x
The optimal treatment setting and the member’s ability to benefit from
a different level of care
Evaluation of Suicidality
x
Assessment of suicide risk should include the following (American
Psychiatric Association, Assessment of Patients with Suicidal Behaviors
(APA Guideline), 2003):
o The member’s most current diagnoses
o Current suicidal ideation, plan, and means
o History of suicidal behavior
o The nature of the current crisis or other unique issues that may
have precipitated suicidal behavior
o Relevant familial factors such as family history of attempts,
completion of suicide, and mental illness
x
There is insufficient evidence that a suicide contract reduces risk,
especially when the member is in crisis, agitated, psychotic, impulsive,
or intoxicated (APA Guideline, 2010).
Special Considerations for Evaluating Children and Adolescents (American
Academy of Children and Adolescent Psychiatry, Parameter for Depressive
Disorders (AACAP Guideline), 2007):
x
Younger children may exhibit behavioral problems such as social
withdrawal, aggressive behavior, apathy, sleep disruption, and weight
loss.
x
Adolescents may present with somatic complaints, self-esteem
problems, rebelliousness, poor performance in school, or a pattern of
engaging in risky or aggressive behavior.
x
A variety of informants should be used in evaluating children and
adolescents, including parents and teachers.
Differential Diagnosis
x
Differential diagnosis should be conducted as part of the evaluation to
identify medical and/or psychiatric disorders that may mimic or overlap
with the symptoms of MDD or Dysthymic Disorder (APA Guideline,
2010).
x
Due to the risks of misdiagnosis and differing treatment
recommendations for MDD/Dysthymic Disorder and Bipolar Disorder,
careful differential diagnosis will ensure the most appropriate care is
delivered (i.e., the correct diagnosis is made and appropriate treatment
goals are set) and should be a routine part of the evaluation with the
following considerations (APA Guideline, 2010):
Page 7 of 24
o Major depressive episodes or recurrent depressive episodes are
common in the course of both Bipolar I and II.
o Acute psychosis, a history of mania or hypomania, and/or a
family history of Bipolar Disorder may be indicators of the need
for additional evaluation and screening for Bipolar Disorder.
Treatment Planning
At the time treatment begins (within 24 hours for inpatient, residential and partial
hospital settings; and within 3 treatment days for intensive outpatient and
outpatient settings) the provider and, whenever possible, the member use the
findings of the initial evaluation and the diagnosis to develop a treatment plan.
The treatment plan should address (LOCGs, 2014):
x
Specific treatments including the type, amount, frequency and duration
of each treatment;
x
The expected outcome for each problem to be addressed expressed in
terms that are measurable, functional, time-framed and directly related
to the “why now” factors; and
x
How the member’s family and other natural resources will participate in
treatment when clinically indicated; and
x
How treatment will be coordinated with other providers as well as with
agencies or programs with which the member is involved.
x
As needed, the treatment plan also includes interventions that further
engage the member in treatment, that promote the member’s
participation in care, promote informed decisions, and support the
member’s broader recovery and resiliency goals.
o Examples include psychoeducation, motivational interviewing,
recovery and resiliency planning, advance directive planning,
and facilitating involvement with self-help and wraparound
services.
x
Treatment focuses on addressing the “why now” factors to the point
that the member’s condition can be safely, efficiently and effectively
treated in a less intensive level of care, or treatment is no longer
required.
x
The provider informs the member of safe and effective treatment
alternatives, potential risks and benefits, and the member gives
informed consent. In providing informed consent, the member
acknowledges willingness and ability to participate in treatment
including any safety precautions; and
Page 8 of 24
x
A change in the member’s condition prompts a reassessment of the
treatment plan and re-evaluation of level of care. When the member’s
condition has not improved or it has worsened, the reassessment
should determine whether the diagnosis is accurate, the treatment plan
should be modified, or the member’s condition should be treated in
another level of care.
Psychotherapy
x
Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT)
are recommended first line forms of psychotherapy for the treatment
of MDD. For Dysthymic Disorder, optimal treatment is a combination
of psychosocial interventions and pharmacotherapy (APA Guideline,
2010).
x
CBT combines cognitive therapy and behavioral therapy. Cognitive
therapy attempts to modify the dysfunctional thoughts, beliefs, and
attitudes (e.g., “I’m no good,” “there’s nothing I can do,” or “my
situation is hopeless”) that maintain behaviors associated with
depression. Behavioral therapy focuses upon modifying the patient’s
problematic behavioral responses (e.g., social isolation and inactivity)
to environmental stimuli or dysfunctional thoughts (Katon, W., RoyByre, P., Sullivan, D., as cited in uptodate.com).
x
Interpersonal therapy addresses problematic interpersonal
relationships or circumstances that are directly related to the current
depressive episode. The therapy focuses upon four types of
problems: grief over loss (e.g., death of a spouse), role disputes (e.g.,
conflicts at work or home about expectations from the relationship),
role transitions (e.g., childbirth, divorce, or retirement), and
interpersonal skill deficits (e.g., pervasive problems starting and
maintaining relationships, and chronically contentious and unfulfilling
relationships) (Katon, et al., as cited in uptodate.com).
Pharmacotherapy
x
Consider Sequenced Treatment Alternatives to Relieve Depression
(STAR*D) or Texas Medication Algorithm Project (TMAP)
recommendations for medication management that defines, treatment
strategies, in what order or sequence, and in what combination(s)
with the least side effects (National Institute of Mental Health (2010).
Sequenced Treatment Alternatives to Relieve Depression; Texas
Department of State Health Services, 2010).
x
Buproprion, Venlafaxine, or Mirtazapine and SSRI and SNRI class
medications are first line agents for the treatment of MDD and
Dysthymic Disorder in addition to other current FDA approved
medications for the treatment of MDD or Dysthymic Disorder. For
Dysthymic Disorder, there are no specific agents that have been
shown more effective than others (APA Guideline, 2010).
Page 9 of 24
x
Consider combining a SSRI with an antipsychotic agent for
depressive symptoms with psychotic features (APA Guideline, 2010).
x
Consider tricyclic antidepressants for members who have a history of
poor response to standard first line agents, and who have been
successfully treated with tricyclic antidepressants agents (APA
Guideline, 2010).
x
Except for lower initial doses to avoid unwanted effects, the doses of
the antidepressants in children and adolescents are similar to those
used for adult members (AACAP Guideline, 2007).
Measuring Progress
x
Tailoring the treatment plan requires ongoing and systematic
assessment of the member’s needs. This can be facilitated by
integrating clinician and/or member administered rating scale
measurements into initial and ongoing evaluation (APA Guideline,
2010).
x
Clinician rated and/or self-rated scales help determine the course and
effects of treatment (APA Guideline, 2010).
x
Self-rated scales require review, interpretation, and discussion with the
member (APA Guideline, 2010). Commonly used tools include (APA
Guideline, 2010):
o Inventory of Depressive Symptoms (IDS), which is available in
clinician-rated and self-rated versions
o Clinician-rated Hamilton Rating Scale for Depression (HAM-D)
o Clinician-rated Montgomery Asberg Depression Rating Scale
(MADRS)
o Self-rated Patient Health Questionnaire (PHQ-9)
o The Beck Depression Inventory (BDI, BDI-II), copyrighted, 21question multiple-choice self-rated instrument.
Changing or Augmenting the Course of Treatment
x
If the member’s depressive symptoms have not improved or have
worsened prior to the current episode of care, a reassessment is
indicated to stabilize the member’s current symptoms and modify the
overall course of treatment. As part of the reassessment, the treating
provider should verify:
o If the member is following the treatment plan;
o That an adequate dose of medication has been given for an
adequate duration (generally 4-6 weeks) (STAR*D, 2010); and
Page 10 of 24
o That psychotherapy has been or is being skillfully executed and
conducted over an appropriate period of time with an adequate
frequency of visits (to be reassessed every 3-4 months)
(STAR*D, 2010).
x
If it is determined through the process of reassessment that the
member has not adequately responded to prior or current treatment
efforts leading to an exacerbation of symptoms, the following should be
considered:
o The member has been misdiagnosed;
o The frequency or intensity of treatment or the current level of
care is inadequate;
o Consider augmenting initial treatments by increasing the
intensity or frequency of psychotherapy, combining
psychotherapy with medications, or increasing medication to
the upper limit in consideration of efficacy, side effects and
adherence (APA Guideline, 2010).
o Changing to a different antidepressant medication (either from
one in the same class or to one of a different class) using
(STAR*D) second-step treatment recommendations.
o Consider implementation of motivational enhancement
interventions in order to assist the member in engaging into the
treatment process (APA Guideline, 2010).
o Consider supplementing the treatment plan with communitybased and peer support resources (LOCGs, 2013).
o Consider Electroconvulsive Therapy (APA Guideline, 2010).
o If covered, consider TMS
Other Treatments
x
Consider combining pharmacotherapy with psychotherapy for the
following (APA Guideline, 2010):
o Members with moderate to severe MDD if psychosocial issues
are important.
o Member diagnosed with Dysthymic Disorder
x
Consider Electroconvulsive Therapy when there is significant risk to
managing the member’s MDD including the following (APA Guideline,
2010):
o Members who are imminent risk for suicide
o Members who evidence signs/symptoms of psychosis
o Members who evidence substantial cognitive impairment as a
result of the member’s Depression.
Page 11 of 24
o Members who are otherwise severely incapacitated
x
When covered by the benefit plan, consider Transcranial Magnetic
Stimulation (TMS) as indicated by the Coverage Determination
Guideline for TMS
Discharge Planning
x
During admission/initiation of treatment, the provider and, whenever
possible, the member update the initial discharge plan in response to
changes in the member’s condition ensuring that:
o An appropriate discharge plan is in place prior to discharge;
o The discharge plan is designed to mitigate the risk that the
“why now” factors which precipitated admission will reoccur;
and
o The member agrees with the discharge plan.
x
For members continuing treatment, the discharge plan includes:
o The discharge date;
o The level, modalities and recommended frequency of the
next level of care;
o The name(s) of the provider(s) who will deliver treatment;
o The date(s) of the first treatment appointment (s) including
the first medication management visit;
o The name, dosages and frequencies of each medication, a
prescription sufficient to last until the first medication
management visit, and an appointment for necessary lab
tests if pharmacotherapy is part of post-discharge care;
o Resources to assist the member with overcoming barriers to
care such as lack of transportation or child care;
o Recommended self-help and community support services;
and
o What should be done in the event that there is a crisis prior
to the first appointment.
x
For members not continuing treatment, the discharge plan includes:
o The date treatment will end;
o Recommended self-help and community support services;
o Information about what the member should do in the event of
a crisis, or to resume services.
o The provider shares the discharge plan and all pertinent
clinical information with the provider(s) at the next level of
care prior to discharge.
Page 12 of 24
o The provider shares the discharge plan with the Care
Advocate to ensure coverage and that necessary prior
authorizations or notifications are completed prior to
discharge.
o Notification of the Care Advocate that the member is
discontinuing treatment also serves to trigger outreach and
assistance to the member.
o The provider coordinates discharge with agencies and
programs such as the school or court system with which the
member has been involved as appropriate
o If the member refuses further treatment or repeatedly does
not adhere with recommended treatment despite attempts to
enhance the member’s engagement, the provider explains
the risk of discontinuing treatment to the member.
PART III: LEVEL OF CARE CRITERIA
Choice of the most appropriate treatment setting should take into consideration
all of the following (LOCGs, 2014):
x
The member is eligible for benefits.
- AND -
x
The member’s current condition cannot be safely, efficiently and
effectively assessed and/or treated in a less intensive setting due to
changes in the member’s signs and symptoms, level of functioning,
and/or psychosocial and environmental factors (i.e., the “why now”
factors leading to admission).
o Failure of treatment in a lower level of care is not a prerequisite
for authorizing coverage.
- AND -
x
The member’s condition and proposed services are covered under the
benefit plan.
- AND -
x
Services are within the scope of the provider’s professional training
and licensure.
- AND -
x
Services are:
o Consistent with generally accepted standards of clinical
practice.
Page 13 of 24
o Consistent with services backed by credible research soundly
demonstrating that the services will have a measurable and
beneficial health outcome, and are therefore not considered
experimental.
o Consistent with Optum’s clinical best practice guidelines.
o Clinically appropriate for the member’s behavioral health
condition based on generally accepted standards of clinical
practice and benchmarks.
- AND x
There is a reasonable expectation that services will improve the
member’s presenting problems within a reasonable period of time.
Improvement of the member’s condition is indicated by the reduction or
control of the acute signs and symptoms that necessitated treatment in
a level of care.
o Improvement in this context is measured by weighing the
effectiveness of treatment against evidence that the member’s
signs and symptoms will deteriorate if treatment in the current
level of care ends. Improvement must also be understood within
the broader framework of the member’s recovery and resiliency
goals.
- AND -
x
Treatment is not primarily for the purpose of providing social, custodial,
recreational, or respite care.
Outpatient
Admission Criteria
x
The member presents with symptoms of a behavioral health condition.
- OR -
x
The member’s psychosocial functioning is impaired or is deteriorating
due to a behavioral health condition.
- OR -
x
The member has a behavioral health condition which requires
pharmacological treatment.
- AND -
x
The member is not at imminent risk for harm to self or others.
- AND -
Page 14 of 24
x
The member exhibits adequate behavioral control to be treated in this
setting.
- AND -
x
Co-occurring substance use disorders, if present, are stable and are
unlikely to undermine treatment of the mental health condition at this
level of care.
Additional Outpatient considerations include:
x
The frequency and duration of outpatient visits should allow for safe
and timely achievement of treatment goals, and support the member’s
recovery/resiliency. Multiple factors may impact frequency and duration
of treatment including the goals of treatment, the member’s
preferences, best practice evidence to support frequency and duration,
and the degree of intensity needed to monitor and address imminent
risk to the member.
x
Initially, the frequency of outpatient visits generally varies from weekly
in routine cases to as often as several times a week. As the member’s
functional status improves, the frequency of visits should decrease to
meet the member’s current needs in achieving those goals.
x
Some patients may undergo a course of treatment which increases
their level of functioning, but then reach a point where further
significant increase is not expected. When stability can be maintained
without further treatment or with less intensive treatment, the services
are no longer necessary (Centers for Medicare and Medicaid Benefits
Policy Manual, 2013).
x
If a patient reaches a point in his/her treatment where further
improvement does not appear to be indicated, and there is no
reasonable expectation of improvement, outpatient services are no
longer considered reasonable or necessary (Centers for Medicare and
Medicaid, Local Coverage Determination (LCD), 2013).
Intensive Outpatient Program
Admission Criteria
x
Moderate symptoms of a mental health condition cannot be managed
in a less intensive level of care and/or a higher level of care may be
required if an Intensive Outpatient Program is not provided.
- OR -
x
Moderate impairment in the member’s psychological, social,
occupational, educational, or other area of functioning has impacted
the member’s ability to perform regular daily activities as compared to
baseline.
- OR -
Page 15 of 24
x
The member requires the support of a structured environment to
complete treatment goals and develop a plan for post-discharge
services in a less intensive setting.
- AND -
x
The member is not at imminent risk of serious harm to self or others.
- AND -
x
The member’s co-occurring medical, mental health or substance use
conditions can be safely managed in an intensive outpatient program.
- AND -
x
The member and/or his/her family/social support system understands
and can comply with the requirements of an intensive outpatient
program.
Partial Hospital/Day Treatment Program
Admission Criteria
x
The member’s psychosocial functioning has become impaired by
severe symptoms of a mental health condition, and treatment cannot
be adequately managed in a less intensive level of care.
- OR -
x
The member’s mood, affect or cognition has deteriorated to the extent
that a higher level of care will likely be needed if treatment in Partial
Hospital/Day Treatment Program is not provided.
- OR -
x
The member has a non-supportive living situation creating an
environment in which the member’s mental health condition is likely to
worsen without the structure and support of Partial Hospital/Day
Treatment Program.
- OR -
x
The member has completed Acute Inpatient or Residential Treatment
Center, and requires the structure and monitoring available in Partial
Hospital/Day Treatment Program.
- AND -
x
The member is not at imminent risk of serious harm to self or others.
- AND -
x
Co-occurring medical conditions, if present, can be safely managed in
an outpatient setting.
- AND -
Page 16 of 24
x
Co-occurring substance use disorders, if present, can be treated in a
dual diagnosis program, or can be safely managed at this level of care.
o The member is not at risk for severe withdrawal or delirium
tremens.
- AND -
x
The member or his/her support system understands and can comply
with the requirements of a Partial Hospital/Day Treatment Program, or
the member is likely to participate in treatment with the structure and
supervision afforded by a Partial Hospital/Day Treatment Program.
Residential Treatment Program
Admission Criteria
x
The member is experiencing a disturbance in mood, affect or cognition
resulting in behavior that cannot be safely managed in a less restrictive
setting.
- OR -
x
There is an imminent risk that severe, multiple and/or complex
psychosocial stressors will produce significant enough distress or
impairment in psychological, social, occupational/educational, or other
important areas of functioning to undermine treatment in a lower level
of care.
- OR -
x
The member has a co-occurring medical disorder or substance use
disorder which complicates treatment of the presenting mental health
condition to the extent that treatment in a Residential Treatment Center
is necessary.
- AND -
x
The member is not at imminent risk of serious harm to self or others.
Inpatient
Admission Criteria
x
The symptoms of a mental health condition require immediate care
and treatment to avoid jeopardy to life or health. Examples include the
following:
ƒ
The member is at imminent risk of harm to self or others as
evidenced by, for example:
ƒ
The member has made a recent and serious suicide
attempt;
Page 17 of 24
ƒ
The member is exhibiting current suicidal ideation
with intent, realistic plan and/or available means, or
other serious life threatening, self-injurious
behavior(s);
ƒ
The member has recently exhibited self-mutilation
that is medically significant and/or potentially
dangerous;
ƒ
The member has made recent and seriously
physically destructive acts that indicate a high risk for
recurrence and serious injury to self of others;
- OR -
x
There has been a deterioration in the member’s psychological, social,
occupational/educational, or other important area of functioning, and
the member is unable to safely and adequately care for him/herself;
- OR -
x
There is an imminent risk that severe, multiple and/or complex
psychosocial stressors will produce enough distress or impairment in
psychological, social, occupational/educational, or another important
area of functioning to undermine treatment at a lower level of care;
- OR -
x
The member has a co-occurring medical disorder or substance use
disorder which complicates treatment of the presenting mental health
condition to the extent that 24-hour management is necessary.
Continued Stay Criteria for All Levels of Care
x
The admission criteria is still met and the member is making progress
in addressing the admission criteria (LOCGs, 2014);
- AND -
x
The “Why Now” for the current episode of care is being addressed and
integrated into the discharge plan (LOCGs, 2014);
- AND -
x
The discharge plan is being updated in response to changes in the
member’s condition, the member’s preferences and goals, the
understanding of the “why now” for the current episode of care, and the
availability of services at the next level of care (LOCGs, 2014);
- AND -
x
The provider is administering evidence-based interventions and clinical
best practices described above of sufficient intensity to address the
member’s treatment needs (LOCGs, 2014);
- AND -
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x
The member’s family/social supports are being engaged to actively
participate in the member’s treatment and recovery/resiliency as
clinically indicated (LOCGs, 2014).
Discharge Criteria for All Levels of Care
x
The criterion for admission is no longer met when, for example
(LOCGs, 2014):
o The goals for the current episode of care have been
accomplished;
- OR o The member requires primarily social, custodial, recreational or
respite care;
- OR o The member’s symptoms are a result of a diagnosis that
requires transfer to a medical/surgical setting for appropriate
treatment;
- OR o The member is unwilling or unable to participate in treatment
and involuntary treatment or guardianship is not being pursued;
- OR o In the case of inpatient treatment, there is no imminent risk, the
member does not wish further treatment and the member has
an established and engaged family/support system to support
the member’s recovery/resiliency and transition to a less
intensive level of care;
- OR o In RTC, PHP, IOP or outpatient levels of care, the member’s
condition has worsened, requiring a more intensive level of
care.
PART IV: ADDITIONAL RESOURCES
Clinical Protocols
Optum maintains clinical protocols that include the Level of Care Guidelines and
Best Practice Guidelines which describe the scientific evidence, prevailing
medical standards and clinical guidelines supporting our determinations
regarding treatment. These clinical protocols are available to Covered Persons
upon request, and to Physicians and other behavioral health care professionals
on providerexpress.com
Peer Review
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Optum will offer a peer review to the provider when services do not appear to
conform to this guideline. The purpose of a peer review is to allow the provider
the opportunity to share additional or new information about the case to assist
the Peer Reviewer in making a determination including, when necessary, to
clarify a diagnosis
Second Opinion Evaluations
Optum facilitates obtaining a second opinion evaluation when requested by an
enrollee, provider, or when Optum otherwise determines that a second opinion is
necessary to make a determination, clarify a diagnosis or improve treatment
planning and care for the member.
Referral Assistance
Optum provides assistance with accessing care when the provider and/or
enrollee determine that there is not an appropriate match with the enrollee’s
clinical needs and goals, or if additional providers should be involved in delivering
treatment.
PART V: DEFINITIONS
Cognitive Behavioral Therapy (CBT) A classification of therapies that are
predicated on the idea that behavior and feelings are caused by thoughts.
Diagnostic and Statistical Manual of the American Psychiatric Association
(DSM) A manual produced by the American Psychiatric Association which
provides the diagnostic criteria for mental health and substance use disorders,
and other problems that may be the focus of clinical attention. Unless otherwise
noted, the current edition of the DSM applies.
Electroconvulsive Therapy (ECT) A treatment technique which provokes a
therapeutic response by applying an electrical current to the brain.
Inpatient A secured and structured hospital-based service that provides 24-hour
nursing care and monitoring, assessment and diagnostic services, treatment, and
specialty medical consultation services with an urgency that is commensurate
with the member’s current clinical need.
Intensive Outpatient Program A freestanding or hospital-based program that
maintains hours of service for at least 6 hours per week. It may be used as an
initial point of entry into care, as a step up from routine outpatient services, or as
a step down.
Interpersonal Therapy A brief and highly structured manual-based form of
psychotherapy which focuses on understanding and improving the handling of
interpersonal events such as disputes, role transitions and impoverished
relationships that, if not addressed, may impact the development of mental
illness.
Page 20 of 24
Major Depressive Disorder According to the DSM, Major Depressive Disorder
is a form of Mood Disorder whose essential feature is the presence of a Major
Depressive episode of at least two weeks duration during which there is either
depressed mood or the loss of interest or pleasure in nearly all activities.
Mental Illness Those mental health or psychiatric diagnostic categories that are
listed in the current Diagnostic and Statistical Manual of the American Psychiatric
Association, unless those services are specifically excluded under the Policy.
Outpatient Visits provided in an ambulatory setting.
Partial Hospital/Day Treatment Program A freestanding or hospital-based
program that maintains hours of service for at least 20 hours per week, and may
also include half-day programs that provide services for less than 4 hours per
day. A partial hospital/day treatment program may be used as a step up from a
less intensive level of care, or as a step down from a more intensive level of care.
Prevailing Medical Standards and Clinical Guidelines means nationally
recognized professional standards of care including, but not limited to, national
consensus statements, nationally recognized clinical guidelines, and national
specialty society guidelines.
Residential Treatment Center A facility-based or freestanding program that
provides overnight services to members who do not require 24-hour nursing care
and monitoring offered in an acute inpatient setting but who do require 24-hour
structure.
Scientific Evidence means the results of controlled clinical trials or other studies
published in peer-reviewed, medical literature generally recognized by the
relevant medical specialty community.
Suicide Contract (a.k.a. No Harm Contract) A non-legal agreement in which
the patient agrees not to attempt suicide.
PART VI: REFERENCES
1. American Academy of Child and Adolescent Psychiatry Practice Parameter
for the Assessment and Treatment of Children and Adolescents with
Depressive Disorders, 2007
http://www.aacap.org/page.ww?section=Practice+Parameters&name=Practic
e+Parameters
2. American Psychiatric Association Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000.
3. American Psychiatric Association, The Practice of Electroconvulsive Therapy:
Recommendations for Treatment, Training and Privileging, 2001.American
Psychiatric Association, Practice Guideline for the Treatment of Patients with
Major Depressive Disorder, 2010. Retrieved from
http://www.psychiatryonline.com/pracGuide/pracGuidehome.aspx
Page 21 of 24
4. American Psychiatric Association, Practice Guideline for the Treatment of
Patients with Suicidal Behaviors, 2003. Retrieved from
http://www.psychiatryonline.com/pracGuide/pracGuidehome.aspx
5. Association for Ambulatory Behavioral Healthcare, Standards and Guidelines
for Partial Hospital Programs, 2008.
6. Center for Medicaid and Medicare Local Coverage Determination, Psychiatric
Inpatient Hospitalization, 2012. http://www.cms.gov/medicare-coveragedatabase/indexes/lcd-alphabetical-index.aspx?bc=AgAAAAAAAAAA&
7. Center for Medicaid and Medicare Local Coverage Determination for
Psychiatric Partial Hospitalization Program, 2013.
http://www.cms.gov/medicare-coverage-database/indexes/lcd-alphabeticalindex.aspx?bc=AgAAAAAAAAAA&
8. Center for Medicaid and Medicare Local Coverage Determination for
Repetitive Transcranial Magnetic Stimulation, 2012.Katon, W., Roy-Byre, P.,
Sullivan, D. Unipolar depression in adults: Management and treatment.
Retrieved from www.uptodate.com, 2014.
9. National Institute of Mental Health (2010). Sequenced Treatment Alternatives
to Relieve Depression. Retrieved from
http://www.nimh.nih.gov/trials/practical/stard/stard-treatment-flowchart.pdf
10. Optum Level of Care Guidelines, 2014. Retrieved from
https://providerexpress.com/html/clinResources.html
11. Optum Technology Assessment (2013). NeuroStar Transcranial Magnetic
Stimulation (TMS) Therapy for Major Depression.
12. Optum Technology Assessment (2013). Brainsway Deep Transcranial
Magnetic Stimulation (DTMS) for Major Depression.
13. Texas Department of State Health Services (2010). Texas Medication
Algorithm Project Procedural Manual. Retrieved from
http://www.pbhcare.org/pubdocs/upload/documents/TMAP%20Depression%2
02010.pdf
14. UnitedHealthcare Generic Certificate of Coverage, 2001.
15. UnitedHealthcare Generic Certificate of Coverage, 2007.
16. UnitedHealthcare Generic Certificate of Coverage, 2009.
17. UnitedHealthcare Generic Certificate of Coverage, 2011.
PART VII: CODING
The Current Procedural Terminology (CPT) codes and HCPCS codes listed in this guideline are
for reference purposes only. Listing of a service code in this guideline does not imply that the
service described by this code is a covered or non-covered health service. Coverage is
determined by the benefit document.
Limited to specific CPT and HCPCS codes? X Yes … No
90791
Psychiatric diagnostic evaluation
90791 plus interactive add-on code (90785)
Psychiatric diagnostic evaluation (interactive)
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90832
90832 plus interactive add-on code (90785)
90832 plus pharmacological add-on code
(90863)
90834
90834 plus interactive add-on code (90785)
90834 plus pharmacological add-on code
(90863)
90837
90837 plus interactive add-on code (90785)
90837 plus pharmacological add-on code
(90863)
90839
90839 plus interactive add-on code (90785)
90846
90847
90849
90853
90853 plus interactive add-on code (90785)
90867
90868
90869
G0410
G0411
H0015
H0035
Psychotherapy, 30 minutes with patient and/or
family
Psychotherapy, 30 minutes with patient and/or
family (interactive)
Psychotherapy, 30 minutes with patient and/or
family (pharmacological management)
Psychotherapy, 45 minutes with patient and/or
family member
Psychotherapy, 45 minutes with patient and/or
family member (interactive)
Psychotherapy, 45 minutes with patient and/or
family member (pharmacological management)
Psychotherapy, 60 minutes with patient and/or
family member
Psychotherapy, 60 minutes with patient and/or
family member (interactive)
Psychotherapy, 60 minutes with patient and/or
family member (pharmacological management)
Psychotherapy for crisis, first 60 minutes
Psychotherapy for crisis, first 60 minutes
(interactive)
Family psychotherapy without the patient
present
Family psychotherapy, conjoint psychotherapy
with the patient present
Multiple-family group psychotherapy
Group psychotherapy (other than of a multiplefamily group)
Group psychotherapy (other than of a multiplefamily group) (interactive)
Therapeutic Repetitive Transcranial Magnetic
Stimulation Treatment; Initial including cortical
mapping, motor threshold determination,
delivery and management
Therapeutic Repetitive Transcranial Magnetic
Stimulation Treatment; Subsequent delivery
and management, per session
Therapeutic Repetitive Transcranial Magnetic
Stimulation Treatment; Subsequent motor
threshold redetermination with delivery and
management
Group psychotherapy other than of a multiple
family group, in a partial hospitalization setting,
approximately 45 to 50 minutes
Interactive group psychotherapy, in a partial
hospitalization setting, approximately 45 to 50
minutes
Intensive outpatient (treatment program that
operates at least 3 hours/day and at least 3
days/week and is based on an individualized
treatment plan), including assessment,
counseling; crisis intervention, and activity
therapy
Mental health partial hospitalization, treatment,
less than 24 hours
Page 23 of 24
S0201
S9480
Partial hospitalization services, less than 24
Intensive outpatient psychiatric services, per
die
Limited to specific diagnosis codes?
296.2x, 296.3x
300.4
296.23
X Yes … No
Major Depressive Disorder
Dysthymic Disorder
Major Depressive Disorder; Single Episode
without Psychotic Features
Major Depressive Disorder, Recurrent Episode
without Psychotic Features
296.33
Limited to place of service (POS)?
… Yes X No
Limited to specific provider type?
… Yes X No
Limited to specific revenue codes?
100-160
X Yes … No
(Range describes various all-inclusive inpatient
services)
(Range describes various unbundled
behavioral health treatments/services)
(Range describes various sites that provider
24-hour services)
900-919
1000-1005
PART VIII: HISTORY
Revision Date
8/2010
4/2012
5/2013
4/2014
Name
L. Urban
L. Urban
L. Urban
L. Urban
Revision Notes
Version 1-Final
Version 2-Final
Version 1-Final Consolidated
Version 2-Final Consolidated
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