Coverage Determination
COVERAGE DETERMINATION GUIDELINE OPTUM™ By United Behavioral Health Treatment of Dissociative Identity Disorder Guideline Number: BHCDG822014 Product: Effective Date: September, 2013 2001 Generic UnitedHealthcare COC/SPD Revision Date: October, 2014 2007 Generic UnitedHealthcare COC/SPD 2009 Generic UnitedHealthcare COC/SPD 2011 Generic UnitedHealthcare COC/SPD Table of Contents: Instructions for Use………………………2 Key Points………………………………...2 Benefits…………………………………….2 Clinical Best Practices…………………...5 Level of Care Criteria…………………...11 Additional Resources…………………...18 Definitions………………………………..19 Related Coverage Determination Guidelines: Related Medical Policies: Level of Care Guidelines International Society for Study of Trauma & Dissociation, Guidelines for Treating Dissociative Identity Disorder in Adults, 2011 Optum Behavioral Health Sciences Literature Review, Dissociative Identity Disorder, 2013 References……………………………....19 Coding…………………………………....20 History…………………………………….22 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. Treatment of Dissociative Identity Disorder Page 1 of 21 Coverage Determination Guideline Confidential and Proprietary, © Optum 2014 Optum is a brand used by United Behavioral Health and its affiliates. Key Points Dissociative Identity Disorder (DID) is characterized by the presence of two or more distinct identities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self, that recurrently take control of the individual’s behavior, with the inability to recall personal information that cannot be explained by ordinary forgetfulness. The disturbance is not due to the effects of substance use or due th to a medical (Diagnostic and Statistical Manual of Mental Disorders, 5 ed.; DSM-5; American Psychiatric Association, 2013). Benefits are available for covered services that are not otherwise limited or excluded. Pre-notification is required for inpatient, residential treatment, partial hospital/day treatment, intensive outpatient treatment programs and home-based outpatient treatment. Services should be consistent with evidence-based interventions and clinical best practices as described in Part II, and should be of sufficient intensity to address the member's needs (Certificate of Coverage, 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. Benefits Benefits include the following services: Diagnostic evaluation and assessment Treatment planning Referral services Medication management Individual, family, therapeutic group and provider-based case management services 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 Those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following: Treatment of Dissociative Identity Disorder Page 2 of 21 Provided for the purpose of preventing, diagnosing or treating a sickness, injury, mental illness, substance abuse, or their symptoms. Consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines as described below. Not provided for the convenience of the Covered Person, Physician, facility or any other person. Described in this Certificate of Coverage under Section 1: Covered Health Services and in the Schedule of Benefits. 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: "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. "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, or a partial hospital/day treatment program 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 Treatment of Dissociative Identity Disorder Page 3 of 21 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: Not consistent with generally accepted standards of medical practice for the treatment of such conditions. 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. 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. 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. The following are examples of services that are inconsistent with the Level of Care Guidelines and Best Practice Guidelines (not an all inclusive list): Services that deviate from the indications for coverage summarized earlier in this document. Admission to an inpatient, residential treatment, partial hospital/day treatment program or intensive outpatient program without evidencebased treatment of acute symptoms. Admission to an inpatient, residential treatment, partial hospital/day treatment program or intensive outpatient program for the sole purpose of awaiting placement in a long-term facility. Admission to an inpatient, residential treatment, partial hospital/day treatment program or intensive outpatient program that does not provide adequate nursing care and monitoring, or physician coverage. 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 Treatment of Dissociative Identity Disorder Page 4 of 21 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): The member’s chief complaint, A description of the acute condition or exacerbation of a chronic condition; The “why now” factors; The member’s psychiatric and medical histories including the histories of substance use, abuse and trauma; The member’s history of treatment; Psychosocial and environmental problems; Mental status examination; Physical examination (when appropriate); Risk factors including those related to harm to self or others, as well as risk stemming from co-occurring behavioral health or medical conditions; Assessment of the member’s use of coping strategies; The member’s readiness for change; The member’s instructions for treatment or appointment of an agent to make decisions about mental health treatment; and The member’s recovery and resiliency goals. Evaluation of Dissociative Symptoms Assessment of dissociative symptoms should include the following (ISSD, 2011): o Comprehensive clinician-administered structured interviews (Structured Clinical Interview for Dissociative Disorders-SCID-DR; Dissociative Disorders Interview Schedule-DDIS) o Comprehensive self-report instruments (Multidimensional Inventory of Dissociation-MID) Treatment of Dissociative Identity Disorder Page 5 of 21 o Brief self-report screening instruments (Dissociative Experiences Scale-DES; Dissociation Questionnaire-DIS-Q; Somatoform Dissociation Questionnaire-SDQ-20) o Other psychological tests when indicated and according to the Optum Psychological Testing Guidelines (MMPI, MCMI-III) o A detailed history of member’s trauma(s) and pattern of dissociation. Differential Diagnosis To ascertain that the full DID criteria have been met, careful differential diagnosis will ensure the most appropriate care is delivered and appropriate treatment goals are developed. Differential diagnosis should identify common conditions that mimic or overlap with the symptoms of DID (i.e., PTSD, Affective Disorders, Substance Use Disorders, Psychotic Disorders, Borderline Personality Disorder, medical conditions, and Dissociative Disorder NOS) (ISSD, 2011). During the course of a DID differential diagnosis, the five most commonly missed diagnoses include Bipolar Disorder, Affective Disorders, Psychotic Disorders, Seizures and Borderline Personality Disorder (ISSD, 2011). Dissociative Identity Disorder is most often misdiagnosed when (ISSD, 2011): o Clinicians who specialize in DID fail to identify nondissociative disorders where dissociative symptoms are present (PTSD, Somatization Disorder, and Panic Disorder). o Clinicians assume that amnesia or identity fragmentation equates to a DID diagnosis. o Clinicians mistake identity problems common in individuals with personality disorders as symptoms of DID. o Mood changes in individuals with Bipolar Disorder are confused with symptoms DID. o Delusions associated with Psychotic Disorders are mistaken for DID symptoms (e.g., being inhabited by other people) o Dissociative symptoms are present with a non-dissociative primary diagnosis (e.g., Personality Disorder with dissociative symptoms and identity disturbances) o The clinician is not alert to the possibility of factitious or malingering presentations of DID especially when legal matters exist. Treatment Planning Treatment of Dissociative Identity Disorder Page 6 of 21 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): Specific treatments including the type, amount, frequency and duration of each treatment; 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 How the member’s family and other natural resources will participate in treatment when clinically indicated; and How treatment will be coordinated with other providers as well as with agencies or programs with which the member is involved. 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. Examples include psychoeducation, motivational interviewing, recovery and resiliency planning, advance directive planning, and facilitating involvement with self-help and wraparound services. 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. 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 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 There is minimal evidence as to the effectiveness of any one approach for the treatment of DID. The literature includes the following recommendations (Optum DID Literature Review, 2013): Treatment of Dissociative Identity Disorder Page 7 of 21 The goal of treatment for individuals diagnosed with DID is to improve the member’s overall level of functioning and reduce comorbid symptoms (e.g., depression and PTSD) (ISSD, 2011). Treatment should first and foremost address the member’s functional impairments, and secondarily help the member to address their experience of dissociation and trauma. A realistic long-term outcome for some members may be to attain a sufficient level of functioning although they may continue to experience some dissociative symptoms (ISSD, 2011). DID is commonly treated as a trauma-based disorder such as PTSD, with the use of Dialectical Behavior Therapy and Cognitive Behavioral approaches, where phased treatment targeting modulation of affect, impulse control, stabilization from crises, and improving interpersonal skills results in better treatment outcomes and lower dropout rates (Optum DID Literature Review, 2013). Therapy that incorporates or modifies techniques such as Cognitive Behavioral Therapy (CBT), Eye-Movement Desensitization and Reprocessing (EMDR), Dialectical Behavior Therapy (DBT) and Sensorimotor Psychotherapy are most commonly adapted into the phased approach to treatment (ISSD, 2011). A phase-oriented treatment approach may include the following components (ISSD, 2011): o Phase 1: Establishing safety, stabilization, and symptom reduction for daily life functioning: The focus is on establishing the therapeutic alliance, educating the member about the diagnosis, helping the member maintain personal safety, control symptoms, build stress tolerance and enhance basic life functioning (ISSD, 2011). o Phase 2: Confronting, working through, and integrating traumatic memories: The focus is on addressing the member’s trauma(s). This includes helping the member remember, tolerate, process and integrate overwhelming past events, including cognitive reframing and strengthening adaptive responses of exposure to traumatic memories (ISSD, 2011). Full awareness that one has experienced the trauma and that trauma is in the past should be accomplished in phase 2 (ISSD, 2011). o Phase 3: Rehabilitation for overall life adaptation and coping: Treatment of Dissociative Identity Disorder Page 8 of 21 The focus is on making additional gains in coping skills, decreasing remaining comorbid symptoms, and improving quality of life. There should be achievement of a more solid and stable sense of self and of relating to others (ISSD, 2011). In phase 3, the member is better able to focus less on past traumas and deal more effectively with current problems (SSD, 2011). Treatment of DID and comorbid symptoms (e.g., Depression and PTSD) with a phase-oriented DBT approach can be used as a standalone treatment model (Optum DID Literature Review, 2013). Experts caution against addressing alternative identities which may be harmful due to the suggestion or reinforcement of alternate personalities (Optum DID Literature Review, 2013). It is suggested that clinicians focus on the feelings associated with the dissociation the member is experiencing and its use as a short-term coping mechanism that is not effective in the long-term (Optum DID Literature Review, 2013). There is currently no evidence to suggest that integration of personality states is a pre-requisite for a successful treatment outcome. For members with an improvement of symptoms, regardless of whether the member has had an integration experience or not, overall improvements were comparable (Optum DID Literature Review, 2013). With the use of a phased approach to treatment, common treatment outcomes depending on the stage include; improved coping skills, decrease of impulsive and self-injurious behavior, decrease in suicide attempts, decrease in hospitalizations, decrease of co-occurring symptoms (e.g., dissociation, PTSD, depression), and an increase in level of adaptive functioning (Optum DID Literature Review, 2013). Frequency and Duration of Psychotherapy For most members, one 45-50 minute weekly outpatient session is often enough to address DID symptoms (ISSD, 2011). When CBT and DBT approaches of therapy are implemented, the typical duration is 4-20 sessions or up to 6 months (Brand, Classen, McNary, & Zaveri, 2009). The need for an increase of sessions or the need for a higher level of care may be limited to circumstances where the member is exhibiting self-destructive or severely dysfunctional behavior (ISSD, 2011). Periods of increases in the frequency or length of sessions should be brief to avoid regression or overdependence on the therapist (ISSD, 2011). Treatment of Dissociative Identity Disorder Page 9 of 21 If weekly sessions do not appear to address the member’s symptoms, the provider should evaluate whether the current level of care and appropriateness of therapeutic modality and/or interventions are addressing the severity of the member’s symptoms; and whether the diagnosis is correct (LOCGs, 2014). Pharmacotherapy There are no medications that primarily treat DID. If medications are used adjunctive to psychotherapy, they should target the presenting symptoms (e.g., hyperarousal and intrusive symptoms associated with PTSD) or any symptoms related to a co-occurring condition (e.g., Depression, Anxiety, etc.) (ISSD, 2011). Discharge Planning 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. 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. o The provider shares the discharge plan with the Care Advocate to ensure coverage and that necessary prior authorization 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 Treatment of Dissociative Identity Disorder Page 10 of 21 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): The member is eligible for benefits. - AND - 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 - The member’s condition and proposed services are covered under the benefit plan. - AND - Services are within the scope of the provider’s professional training and licensure. - AND - Services are: o Consistent with generally accepted standards of clinical practice. 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 - Treatment of Dissociative Identity Disorder Page 11 of 21 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 - Treatment is not primarily for the purpose of providing social, custodial, recreational, or respite care. Outpatient Admission Criteria The member presents with symptoms of a behavioral health condition. - OR - The member’s psychosocial functioning is impaired or is deteriorating due to a behavioral health condition. - OR - The member has a behavioral health condition which requires pharmacological treatment. - AND - The member is not at imminent risk for harm to self or others. - AND - The member exhibits adequate behavioral control to be treated in this setting. - AND - 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: Treatment of Dissociative Identity Disorder Page 12 of 21 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, and best practice evidence to support frequency and duration, and the degree of intensity needed to monitor and address imminent risk to the member. 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. 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). 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 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 - 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 - 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 - The member is not at imminent risk of serious harm to self or others. - AND - Treatment of Dissociative Identity Disorder Page 13 of 21 The member’s co-occurring medical, mental health or substance use conditions can be safely managed in an intensive outpatient program. - AND - 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 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 - 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 - 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 - The member has completed Acute Inpatient or Residential Treatment Center, and requires the structure and monitoring available in Partial Hospital/Day Treatment Program. - AND - The member is not at imminent risk of serious harm to self or others. - AND - Co-occurring medical conditions, if present, can be safely managed in an outpatient setting. - AND - 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 - Treatment of Dissociative Identity Disorder Page 14 of 21 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 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 - 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 - 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 - The member is not at imminent risk of serious harm to self or others. Inpatient Admission Criteria The symptoms of a mental health condition require immediate care and treatment to avoid jeopardy to life or health. Examples include the following: The member is at imminent risk of harm to self or others as evidenced by, for example: The member has made a recent and serious suicide attempt; The member is exhibiting current suicidal ideation with intent, realistic plan and/or available means, or other serious life threatening, self-injurious behavior(s); The member has recently exhibited self-mutilation that is medically significant and/or potentially dangerous; Treatment of Dissociative Identity Disorder Page 15 of 21 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 - 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 - 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 - 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 The admission criteria is still met and the member is making progress in addressing the admission criteria (LOCGs, 2014); - AND - The “Why Now” for the current episode of care is being addressed and integrated into the discharge plan (LOCGs, 2014); - AND - 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 - 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 - 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 The criterion for admission is no longer met when, for example (LOCGs, 2014): Treatment of Dissociative Identity Disorder Page 16 of 21 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 ubhonline Peer Review 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 Treatment of Dissociative Identity Disorder Page 17 of 21 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. 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. Integration Integration is a broad, longitudinal process referring to all work on dissociated mental processes throughout the course of treatment. Intensive Outpatient Program A freestanding or hospital-based program that maintains hours of service for at least 3 hours per day, 2 or more days 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. 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. Treatment of Dissociative Identity Disorder Page 18 of 21 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. PART VI: REFERENCES 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013. 2. Association for Ambulatory Behavioral Healthcare, Standards and Guidelines for Partial Hospital Programs, 2008. 3. Brand, B. L., Classen, C. C., McNary, S. W., & Zaveri, P. (2009). A review of dissociative disorders treatment studies. Journal of Nervous and Mental Disease, 197(9), 646-654. doi: http://dx.doi.org/10.1097/NMD.0b013e3181b3afaa 4. 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& 5. 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& 6. Generic UnitedHealthcare Certificate of Coverage, 2001. 7. Generic UnitedHealthcare Certificate of Coverage, 2007. 8. Generic UnitedHealthcare Certificate of Coverage, 2009. 9. Generic UnitedHealthcare Certificate of Coverage, 2011. 10. International Society for Study of Dissociation, Guidelines for Treating Dissociative Identity Disorder in Adults, 2011.. 11. Optum Behavioral Health Sciences Literature Review, Dissociative Identity Disorder, 2013. 12. Optum Level of Care Guidelines, 2014. 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? 90791 Treatment of Dissociative Identity Disorder X Yes No Psychiatric diagnostic evaluation Page 19 of 21 90791 plus interactive add-on code (90785) 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) G0410 G0411 H0015 H0035 S0201 S9480 Psychiatric diagnostic evaluation (interactive) 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) 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 Partial hospitalization services, less than 24 Intensive outpatient psychiatric services, per die Limited to specific diagnosis codes? 300.14 300.15 X Yes No Dissociative Identity Disorder Other Specified Dissociative Identity Disorder Limited to place of service (POS)? Yes X No Treatment of Dissociative Identity Disorder Page 20 of 21 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 05/2014 10/2014 Name L. Urban L. Urban Treatment of Dissociative Identity Disorder Revision Notes Version 2-Final DSM-5 Version 2-Final Page 21 of 21
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