SCHIZOPHRENIA & SCHIZOAFFECTIVE DISORDERS

Transcription

1 Optum Cverage Determinatin Guideline SCHIZOPHRENIA & SCHIZOAFFECTIVE DISORDERS Plicy Number: BH727SSDCDG_ Effective Date: July, 2017 Table f Cntents Page INSTRUCTIONS FOR USE... 1 BENEFIT CONSIDERATIONS... 1 COVERAGE RATIONALE... 2 APPLICABLE CODES... 2 LEVEL OF CARE GUIDELINES... 4 UNITEDHEALTHCARE BENEFIT PLAN DEFINITIONS... 4 EVIDENCE-BASED CLINICAL GUIDELINES... 5 REFERENCES... 7 ADDITIONAL RESOURCES... 8 HISTORY/REVISION INFORMATION... 8 Relevant Diagnses: Schizphrenia Schizaffective disrder Catatnia INSTRUCTIONS FOR USE This Cverage Determinatin Guideline prvides assistance in interpreting and administering behaviral health benefit plans that are managed by Optum, and U.S. Behaviral Health Plan, Califrnia (ding business as OptumHealth Behaviral Slutins f Califrnia ( Optum-CA )). When deciding cverage, the member-specific benefit plan dcument must be referenced. The terms f the member-specific benefit plan dcument [e.g., Certificate f Cverage (COC), Schedule f Benefits (SOB), and/r Summary Plan Descriptin (SPD)] may differ greatly frm the standard benefit plan upn which this Cverage Determinatin Guideline is based. In the event f a cnflict, the member s specific benefit plan dcument supersedes this Cverage Determinatin Guideline. All reviewers must first identify member eligibility, the member-specific benefit plan cverage, and any federal r state regulatry requirements that supersede the COC/SPD prir t using this Cverage Determinatin Guideline. Other Plicies and Cverage Determinatin Guidelines may apply. Optum reserves the right, in its sle discretin, t mdify its Plicies and Guidelines as necessary. This Cverage Determinatin Guideline is prvided fr infrmatinal purpses. It des nt cnstitute medical advice. Optum may als use tls develped by third parties that are intended t be used in cnnectin with the independent prfessinal medical judgment f a qualified health care prvider and d nt cnstitute the practice f medicine r medical advice. BENEFIT CONSIDERATIONS Befre using this dcument, please check the member s specific benefit plan requirements and any federal r state mandates, if applicable. Pre-Service Ntificatin Admissins t an inpatient, residential treatment center, intensive utpatient, r a partial hspital/day treatment prgram require pre-service ntificatin. Ntificatin f a scheduled admissin must ccur at least five (5) business days befre admissin. Ntificatin f an unscheduled admissin (including emergency admissins) shuld ccur as sn as is reasnably pssible. Benefits may be reduced if Optum is nt ntified f an admissin t these levels f care. Check the member s specific benefit plan dcument fr the applicable penalty and prvisin fr a grace perid befre applying a penalty fr failure t ntify Optum as required. Additinal Infrmatin The lack f a specific exclusin fr a service des nt necessarily mean that the service is cvered. Fr example, depending n the specific plan requirements, services that are incnsistent with Level f Care Guidelines and/r Schizphrenia & Schizaffective Disrders Page 1 f 10

2 prevailing medical standards and clinical guidelines may be excluded. Please refer t the member s benefit dcument fr specific plan requirements. Essential Health Benefits fr Individual and Small Grup Fr plan years beginning n r after January 1, 2014, the Affrdable Care Act f 2010 (ACA) requires fully insured nn-grandfathered individual and small grup plans (inside and utside f Exchanges) t prvide cverage fr ten categries f Essential Health Benefits ( EHBs ). Large grup plans (bth self-funded and fully insured), and small grup ASO plans, are nt subject t the requirement t ffer cverage fr EHBs. Hwever, if such plans chse t prvide cverage fr benefits which are deemed EHBs, the ACA requires all dllar limits n thse benefits t be remved n all Grandfathered and Nn-Grandfathered plans. The determinatin f which benefits cnstitute EHBs is made n a state by state basis. As such, when using this plicy, it is imprtant t refer t the member-specific benefit dcument t determine benefit cverage. COVERAGE RATIONALE Available benefits fr schizphrenia and schizaffective disrders include the fllwing services: Diagnstic evaluatin, assessment, and treatment planning Treatment and/r prcedures Medicatin management and ther assciated treatments Individual, family, and grup therapy Prvider-based case management services Crisis interventin The requested service r prcedure must be reviewed against the language in the member's benefit dcument. When the requested service r prcedure is limited r excluded frm the member s benefit dcument, r is therwise defined differently, it is the terms f the member's benefit dcument that prevails. Per the specific requirements f the plan, health care services r supplies may nt be cvered when incnsistent with generally accepted standards and clinical guidelines: Optum Level f Care Guidelines UnitedHealthcare Benefit Plan Definitins Evidence-Based Clinical Guidelines All services must be prvided by r under the directin f a prperly qualified behaviral health prvider. APPLICABLE CODES The fllwing list(s) f prcedure and/r diagnsis cdes is prvided fr reference purpses nly and may nt be all inclusive. Listing f a cde in this guideline des nt imply that the service described by the cde is a cvered r nncvered health service. Benefit cverage fr health services is determined by the member-specific benefit plan dcument and applicable laws that may require cverage fr a specific service. The inclusin f a cde des nt imply any right t reimbursement r guarantee claim payment. Other plicies and guidelines may apply. CPT Cde Descriptin Interactive cmplexity (list separately in additin t the cde fr primary prcedure) Psychiatric diagnstic evaluatin Psychiatric diagnstic evaluatin with medical services Psychtherapy, 30 minutes with patient Psychtherapy, 30 minutes with patient when perfrmed with an evaluatin and management service(list separately in additin t the cde fr primary prcedure) Psychtherapy, 45 minutes with patient Psychtherapy, 45 minutes with patient when perfrmed with an evaluatin and management service (list separately in additin t the cde fr primary prcedure) Psychtherapy, 60 minutes with patient Psychtherapy, 60 minutes with patient when perfrmed with an evaluatin and management service (list separately in additin t the cde fr primary prcedure) Psychtherapy fr crisis; first 60 minutes Schizphrenia & Schizaffective Disrders Page 2 f 10

3 CPT Cde Psychanalysis Descriptin Psychtherapy fr crisis; each additinal 30 minutes (list separately in additin t the cde fr primary service) Family psychtherapy (withut the patient present), 50 minutes Family psychtherapy (cnjint psychtherapy) (with the patient present), 50 minutes Multiple-family grup psychtherapy Grup psychtherapy (ther than f a multiple-family grup) Pharmaclgic management, including prescriptin and review f medicatin, when perfrmed with psychtherapy services (List separately in additin t the cde fr primary prcedure) HCPCS Cde G0177 G0410 G0411 H0004 H0017 H0018 H0019 H0035 H2001 H2011 H2012 H2013 H2017 H2018 H2019 H2020 S0201 S9480 S9482 S9484 S9485 Descriptin Training and educatinal services related t the care and treatment f patient's disabling mental health prblems per sessin (45 minutes r mre) Grup psychtherapy ther than f a multiple-family grup, in a partial hspitalizatin setting, apprximately 45 t 50 minutes Interactive grup psychtherapy, in a partial hspitalizatin setting, apprximately 45 t 50 minutes Behaviral health cunseling and therapy, per 15 minutes Behaviral health; residential (hspital residential treatment prgram), withut rm and bard, per diem Behaviral health; shrt-term residential (nnhspital residential treatment prgram), withut rm and bard, per diem Behaviral health; lng-term residential (nnmedical, nnacute care in a residential treatment prgram where stay is typically lnger than 30 days), withut rm and bard, per diem Mental health partial hspitalizatin, treatment, less than 24 hurs Rehabilitatin prgram, per 1/2 day Crisis interventin service, per 15 minutes Behaviral health day treatment, per hur Psychiatric health facility service, per diem Psychscial rehabilitatin services, per 15 minutes Psychscial rehabilitatin services, per diem Therapeutic behaviral services, per 15 minutes Therapeutic behaviral services, per diem Partial hspitalizatin services, less than 24 hurs, per diem Intensive utpatient psychiatric services, per diem Family stabilizatin services, per 15 minutes Crisis interventin mental health services, per hur Crisis interventin mental health services, per diem ICD-10 Diagnsis Cde F20.0 Paranid schizphrenia ICD-10 Descriptin F20.1 Disrganized schizphrenia F20.2 Catatnic schizphrenia F20.3 Undifferentiated schizphrenia F20.5 Residual schizphrenia F20.81 Schizphrenifrm disrder F20.89 Other schizphrenia Schizphrenia & Schizaffective Disrders Page 3 f 10

4 ICD-10 Diagnsis Cde ICD-10 Descriptin F20.9 Schizphrenia, unspecified F21 Schiztypal disrder F25.0 Schizaffective disrder, biplar type F25.1 Schizaffective disrder, depressive type F25.8 Other schizaffective disrders F25.9 Schizaffective disrder, unspecified LEVEL OF CARE GUIDELINES Optum / OptumHealth Behaviral Slutins f Califrnia Level f Care Guidelines are available at: The Level f Care Guidelines are a set f bjective and evidence-based behaviral health guidelines used t standardize cverage determinatins, prmte evidence-based practices, and supprt members recvery, resiliency, and wellbeing. UNITEDHEALTHCARE BENEFIT PLAN DEFINITIONS Fr plans using 2001 and 2004 generic UnitedHealthcare COC/SPD, unless therwise specified Cvered Health Service(s) Thse health services prvided fr the purpse f preventing, diagnsing r treating a sickness, injury, mental illness, substance abuse, r their symptms. A Cvered Health Service is a health care service r supply described in Sectin 1: What's Cvered--Benefits as a Cvered Health Service, which is nt excluded under Sectin 2: What's Nt Cvered--Exclusins. Fr plans using 2007 and 2009 generic UnitedHealthcare COC/SPD, unless therwise specified Cvered Health Service(s) Thse health services, including services, supplies, r Pharmaceutical Prducts, which we determine t be all f the fllwing: Prvided fr the purpse f preventing, diagnsing r treating a sickness, injury, mental illness, substance abuse, r their symptms. Cnsistent with natinally recgnized scientific evidence as available, and prevailing medical standards and clinical guidelines as described belw. Nt prvided fr the cnvenience f the Cvered Persn, Physician, facility r any ther persn. Described in the Certificate f Cverage under Sectin 1: Cvered Health Services and in the Schedule f Benefits. Nt therwise excluded in the Certificate f Cverage under Sectin 2: Exclusins and Limitatins. In applying the abve definitin, "scientific evidence" and "prevailing medical standards" shall have the fllwing meanings: "Scientific evidence" means the results f cntrlled clinical trials r ther studies published in peer-reviewed, medical literature generally recgnized by the relevant medical specialty cmmunity. "Prevailing medical standards and clinical guidelines" means natinally recgnized prfessinal standards f care including, but nt limited t, natinal cnsensus statements, natinally recgnized clinical guidelines, and natinal specialty sciety guidelines. Fr plans using 2011 and mre recent generic UnitedHealthcare COC/SPD, unless therwise specified Cvered Health Care Service(s) - health care services, including supplies r Pharmaceutical Prducts, which we determine t be all f the fllwing: Medically Necessary. Described as a Cvered Health Care Service in the Certificate under Sectin 1: Cvered Health Care Services and in the Schedule f Benefits. Nt excluded in the Certificate under Sectin 2: Exclusins and Limitatins. Medically Necessary - health care services prvided fr the purpse f preventing, evaluating, diagnsing r treating a Sickness, Injury, Mental Illness, substance-related and addictive disrders, cnditin, disease r its symptms, that are all f the fllwing as determined by us r ur designee. Schizphrenia & Schizaffective Disrders Page 4 f 10

5 In accrdance with Generally Accepted Standards f Medical Practice. Clinically apprpriate, in terms f type, frequency, extent, site and duratin, and cnsidered effective fr yur Sickness, Injury, Mental Illness, substance-related and addictive disrders, disease r its symptms. Nt mainly fr yur cnvenience r that f yur dctr r ther health care prvider. Nt mre cstly than an alternative drug, service(s) r supply that is at least as likely t prduce equivalent therapeutic r diagnstic results as t the diagnsis r treatment f yur Sickness, Injury, disease r symptms. Generally Accepted Standards f Medical Practice are standards that are based n credible scientific evidence published in peer-reviewed medical literature generally recgnized by the relevant medical cmmunity, relying primarily n cntrlled clinical trials, r, if nt available, bservatinal studies frm mre than ne institutin that suggest a causal relatinship between the service r treatment and health utcmes. If n credible scientific evidence is available, then standards that are based n Dctr specialty sciety recmmendatins r prfessinal standards f care may be cnsidered. We have the right t cnsult expert pinin in determining whether health care services are Medically Necessary. The decisin t apply Dctr specialty sciety recmmendatins, the chice f expert and the determinatin f when t use any such expert pinin, shall be determined by us. We develp and maintain clinical plicies that describe the Generally Accepted Standards f Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supprting ur determinatins regarding specific services. EVIDENCE-BASED CLINICAL GUIDELINES A. Initial evaluatin cmmn criteria and best practices See Cmmn Criteria and Best Practices fr All Levels f Care, available at: Optum recgnizes the American Psychiatric Assciatin s Practice Guidelines fr the Psychiatric Evaluatin f Adults (2016): > Psychiatrists > Practice > Clinical Practice Guidelines B. Screening and Assessment Rating scales such as the Brief Psychiatric Rating Scale (BPRS), Psitive Symptms Rating Scale (PSRS) and the Brief Negative Symptm Assessment (BNSA) may be useful fr assessing the member s presenting symptms, and t peridically measure the member s respnse t treatment (Texas Medicatin Algrithm Prject (TMAP), 2008). Psychiatric assessments fr children and adlescents shuld include screening questins fr psychsis (AACAP, 2013). Diagnstic accuracy may be imprved by using a structured diagnstic interview that is designed fr yuth and includes a mdule fr psychtic illnesses (AACAP, 2013). Risk factrs (e.g., early nset, risk f harm, family histry f Schizphrenia, islatin, unsuccessful treatment at a lwer level f care) shuld be identified (APA, 2004). Strengths and resilience factrs shuld be identified (e.g., family r peer supprts, illness management skills) (APA, 2004). C. Differential diagnsis fr schizphrenia and schizaffective disrders includes (American Psychiatric Assciatin, 2013): Majr Depressive Disrder r Biplar Disrder with psychtic r catatnic features; Schizaffective Disrder Schizphrenifrm Disrder and Brief Psychtic Disrder Delusinal Disrder; Schiztypal Persnality Disrder; Obsessive-Cmpulsive Disrder and Bdy Dysmrphic Disrder; Psttraumatic Stress Disrder; Autism Spectrum Disrder Autism and pervasive develpmental disrders are distinguished frm schizphrenia by the absence f psychtic symptms and by the predminance f the characteristic deviant language patterns, aberrant scial relatedness, r repetitive behavirs (AACAP, 2013). Other cnditins assciated with a psychtic episde. Full-blwn mania in teenagers ften presents with flrid psychsis, including hallucinatins, delusins, and thught disrder (AACAP, 2013) Schizphrenia & Schizaffective Disrders Page 5 f 10

6 Central nervus system infectins, delirium, neplasms, endcrine disrders, genetic syndrmes, autimmune disrders, and txic expsures (AACAP, 2013). Psychtic symptms as a result f substance abuse t include dextrmethrphan, lysergic acid diethylamide, hallucingenic mushrms, psilcybin, peyte, cannabis, stimulants, and inhalants (AACAP, 2013). When drug abuse precedes the develpment f schizphrenia, it is difficult t gauge whether the psychsis represents independent drug effects r the unmasking f the underlying illness in an individual with ther neurbilgical vulnerabilities (AACAP, 2013). D. Treatment planning cmmn criteria and best practices See Cmmn Criteria and Best Practices fr All Levels f Care, available at: Optum recgnizes the American Psychiatric Assciatin s Practice Guidelines fr the Psychiatric Evaluatin f Adults (2016): > Psychiatrists > Practice > Clinical Practice Guidelines E. Psychscial Interventins Psychscial interventins are typically prvided as in cnjunctin with pharmactherapy and are fcused n symptm imprvement and stabilizatin fr Schizphrenia and Schizaffective Disrder (APA, 2009). The aims f psychscial interventins are t facilitate the member s engagement in treatment, as well as t decrease risk and prmte resilience (APA, 2009). Significant scial supprt is required by mst schizphrenic patients. Schizphrenic patients cnstitute nearly ne third f all hmeless individuals. They usually require help with basic scial, ccupatinal, and interactin skills (Ferri s Clinical Advisr, 2016). Family stress can precipitate relapse and re-hspitalizatin. Family interventins can reduce mrbidity (Ferri s Clinical Advisr, 2016). Cgnitive behaviral therapy can reduce the severity f bth psychtic and negative symptms (Ferri s Clinical Advisr, 2016). Integrated treatment that includes assertive cmmunity treatment, family invlvement prgrams, and scial skills training reduces the severity f bth psychtic and negative symptms, reduces cmrbid substance misuse, reduces hspital days, increases adherence t treatment, and increases satisfactin with treatment (Ferri s Clinical Advisr, 2016). F. Pharmactherapy Pharmactherapy Cnsideratins fr Schizphrenia & Schizaffective Disrder Pharmactherapy recmmendatins fr children and adlescents are similar t the adult recmmendatins, althugh age and develpmental risks and benefits f each medicatin shuld be cnsidered prir t use with children and adlescents (AACAP, 2001). Cnsider the fllwing t imprve the likelihd that pharmactherapy will be beneficial: Age and develpmental level f the member, especially when the member is a child/adlescent and the ptential assciated risks f medicatin chice. The need t educate the member and, with the member s dcumented cnsent, their family/scial supprts abut pharmactherapy (APA, 2004); Alternatives t medicatins that have nt prven successful, have resulted in serius side effects, are likely t prduce drug interactins, r are therwise nt in line with the member s preferences (APA, 2004); Aviding verly cmplicated regimens (e.g., when a member is als being treated with medicatins fr ther behaviral health r medical cnditins) will be beneficial (APA, 2004); Acute Pharmactherapy fr Schizphrenia Acute psychsis is usually adequately cntrlled with antipsychtic agents (Ferri s Clinical Advisr, 2016). Few differences in effectiveness exist between first-generatin antipsychtics (e.g., halperidl, perphenazine, fluphenazine, chlrprmazine) and secnd-generatin antipsychtics (e.g., risperidne, lanzapine, quetiapine, ziprasidne, aripiprazle, clzapine, lurasidne) fr nnrefractry patients (Ferri s Clinical Advisr, 2016). First-generatin antipsychtics are slightly mre likely than secnd-generatin antipsychtics t cause a parkinsnian state and eventual tardive dyskinesia (rate f tardive dyskinesia, 15% t 30%). Antiparkinsnian drugs (e.g., benztrpine, amantadine) are used t amelirate the parkinsnism (Ferri s Clinical Advisr, 2016). Risperidne has been shwn t be superir t halperidl fr the preventin f acute psychtic relapse (Ferri s Clinical Advisr, 2016). Schizphrenia & Schizaffective Disrders Page 6 f 10

7 Sedatives (i.e., benzdiazepines and, t a lesser degree, barbiturates) can be used transiently if a patient is in an agitated state (Ferri s Clinical Advisr, 2016). Cnsider a first r secnd generatin antipsychtic as a first-line treatment (Psychpharmaclgical Treatment Recmmendatins fr Schizphrenia (PORT), 2009). Cnsider switching t a different first r secnd generatin antipsychtic as a secnd-line treatment (Texas Medicatin Algrithm Prject (TMAP), 2008). Cnsider clzapine as a third-line treatment. Use f clzapine may be especially apprpriate fr members with recurrent suicidality, members wh have a c-ccurring substance use disrder, r when psitive symptms have persisted fr mre than 2 years (TMAP, 2008). Cnsider cmbining a first r secnd generatin antipsychtic with clzapine r ECT as a furth line treatment r fr treatment resistance (TMAP, 2008). Cnsider use f lng-acting injectable (dept) antipsychtic medicatins when the curse f the member s cnditin r current presentatin make it likely that relapse will ccur after discharge/discntinuatin f treatment (TMAP, 2008). Cncurrent use f multiple first r secnd generatin antipsychtics is typically nt indicated (TMAP, 2009). Cnsider use f adjunctive medicatins t treat symptms f c-ccurring symptms r t address drug interactins and side effects (APA, 2009). Mnitr the member s respnse t treatment clsely and adjust dsage accrdingly: Adjusting the dsage t a therapeutic level may prceed mre slwly during a first episde when there isn t an established histry f treatment (TMAP, 2008). Mnitr fr cmmn side effects such drwsiness, dizziness, metablic changes (e.g., hyperglycemia, diabetes mellitus), tardive dyskinesia, r extrapyramidal side effects (PORT, 2009). Pharmactherapy fr Cntinuus Schizphrenia Relapse preventin is a majr gal f treatment. Antipsychtic agents usually must be cntinued at the same dses that cntrls psychsis. Lng-acting injectable preparatins given biweekly r mnthly can be used (Ferri s Clinical Advisr, 2016). Mst patients frequently switch amng antipsychtics and there is cnsiderable individual variability with regard t antipsychtic respnse and vulnerability t specific adverse effects (Ferri s Clinical Advisr, 2016). Clzapine is mre effective than ther agents fr treatment-refractry patients. Hwever, it requires mnitring t prevent life-threatening adverse effects. Olanzapine may als be mre effective than less expensive first-generatin drugs but has substantial adverse metablic effects (Ferri s Clinical Advisr, 2016). Neurcgnitive imprvement assciated with antipsychtic treatment amng patients with schizphrenia is small and des nt differ between first-generatin and secnd-generatin antipsychtics. Antiparkinsnian agents may als need t be cntinued fr the lng term (Ferri s Clinical Advisr, 2016). Tardive dyskinesia can ccur in as many as 30% f patients with the lng-term use f neurleptics (Ferri s Clinical Advisr, 2016). The negative symptms f schizphrenia can resemble depressin. In additin, depressive disrders may ccur in schizphrenic patients. Antidepressant treatment f the negative symptms is usually nt effective. Hwever, antidepressants can imprve the symptms f a cmrbid depressive episde (Ferri s Clinical Advisr, 2016). Md stabilizers (e.g., lithium, valprate, carbamazepine) are f little use unless the patient has a cmrbid impulse cntrl disrder (Ferri s Clinical Advisr, 2016). Specific antipsychtic medicatins have been assciated with weight gain (i.e., lanzapine and clzapine) and QT prlngatin. Hyperlipidemia and diabetes mellitus are assciated with secnd-generatin antipsychtics, and hyperprlactinemia is assciated with first-generatin antipsychtics. (Risperidne, a secnd-generatin antipsychtic, can als prduce hyperprlactinemia.) Clzapine is assciated with agranulcytsis. Metablic status and weight shuld be screened befre the start f treatment and at regular intervals (Ferri s Clinical Advisr, 2016). Patients with schizphrenia have a higher lifetime incidence f suicide, with 20% attempting n ne r mre ccasins and 5% t 6% cmpleting suicide. Cmrbid use f substances and hpelessness are assciated risk factrs. Clzapine has shwn the ability t decrease the incidence f suicidal attempts in schizphrenia patients (Ferri s Clinical Advisr, 2016). Several 1st and 2nd generatin antipsychtics are available in lng-acting injectable preparatins that may be helpful (Ferri s Clinical Advisr, 2016). Pharmactherapy fr Schizaffective Disrder Atypical r secnd generatin antipsychtics use is the current standard fr the treatment f Schizaffective Disrder with the fllwing cnsideratins (Current Psychiatry, 2010). Schizphrenia & Schizaffective Disrders Page 7 f 10

8 Selecting an apprpriate atypical antipsychtic requires adequate member/prvider dialgue, member educatin, treatment adherence and nging assessment and management f adverse effects (Current Psychiatry, 2010). The use f a md stabilizer may be intrduced as an adjunct t antipsychtic use when depressive r biplar symptms are present and symptms d nt fully respnd t antipsychtic treatment alne (Current Psychiatry, 2010). The use f an antidepressant may be cnsidered as an adjunct t antipsychtic use when depressive symptms persist fllwing the stabilizatin f psychsis, mnitring fr a rapid switch frm depressin t mania and/r mixed state after antidepressant treatment (Current Psychiatry, 2010). Regardless f level f care, pharmactherapy shuld cntinue fr 8-12 weeks t determine medicatin efficacy (Current Psychiatry, 2010). Mnitr fr changes in the balance between psychtic symptms and affective/md symptms. An initial Schizaffective Disrder subtype is frequently unstable and may prgress t Schizphrenia r Majr Depressin/Mania with Psychtic features (Current Psychiatry, 2010). Nn-pharmaclgic therapies shuld be used in cmbinatin with pharmactherapy t achieve the greatest benefit (Current Psychiatry, 2010). Other treatment ptins such as ECT r clzapine may be initiated if the member is nnrespnsive t multiple trials r targeted interventins (Current Psychiatry, 2010). Pharmactherapy During Pregnancy A pregnancy test fr wmen f child bearing ptential shuld be cnsidered as there may be risks t an unbrn fetus and breast-fed infant due t the effects f medicatins (APA, 2004). If pregnancy is cnfirmed, the prvider shuld encurage and mnitr prenatal care t reduce the risk f adverse utcmes such as lw birth weight and still birth as a result f inadequate prenatal care and treatments that are cntraindicated (APA, 2004). The prvider shuld clsely measure the risks and benefits f pharmactherapy thrughut the curse f a member s pregnancy, making adjustments as needed (APA, 2004). Althugh the risk varies accrding t medicatin, the first trimester and withdrawal risk at the time f birth appear t be the perids f highest risk (APA, 2004). Due t metablic effects f atypical antipsychtic medicatin use, there is an increased risk f gestatinal diabetes requiring metablic mnitring thrughut the pregnancy (APA, 2004). Benzdiazepines and md stabilizers pse the highest risk f fetal malfrmatins and behaviral effects (APA, 2004). There is evidence t supprt that there may be milder symptms during pregnancy but an increased risk f exacerbated symptms in the pstpartum perid (APA, 2004). Pharmactherapy Cnsideratins fr Older Adults It is recmmended that lder adults receive a cmbinatin f pharmactherapy and psychscial interventins (APA, 2004). Several age-related physilgical factrs may influence medicatin chice. The fllwing shuld be cnsidered (APA, 2004): Reduced cardiac utput and rgan bld flw and reduced metablism and fat cntent impact the rate f absrptin resulting in prlnged drug effects and greater sensitivity t medicatins. The starting dse shuld be ne quarter t ne half f the usual adult starting dse. The presence f c-ccurring medical cnditins r the use f multiple medicatins further cmplicates pharmactherapy requiring clse mnitring fr ptential risks and interactins. Due t the cgnitive changes that may accmpany aging and Schizphrenia related cgnitive effects, engagement and adherence t medicatin regimens shuld be clsely evaluated. Secnd generatin antipsychtics are generally preferred ver first generatin antipsychtic medicatins due t the risk f extrapyramidal effects such as tardive dyskinesia. There may be a higher risk f falls with the use f secnd generatin antipsychtics. G. Discharge planning cmmn criteria and best practices See Cmmn Criteria and Best Practices fr All Levels f Care : REFERENCES* 1. American Psychiatric Assciatin. Practice guidelines fr the psychiatric evaluatin f adults (3 rd ed.). Arlingtn, VA: American Psychiatric Publishing; Schizphrenia & Schizaffective Disrders Page 8 f 10

9 2. American Psychiatric Assciatin. Diagnstic and statistical manual f mental disrders (5 th ed.). Arlingtn, VA: American Psychiatric Publishing; American Academy f Child and Adlescent Psychiatry, Practice Parameter fr the Assessment and Treatment f Children and Adlescents with Schizphrenia, American Psychiatric Assciatin Diagnstic and Statistical Manual f Mental Disrders, Fifth Editin, American Psychiatric Assciatin, Practice Guideline fr the Treatment f Schizphrenia, American Psychiatric Assciatin, Practice Guideline fr the Treatment f Schizphrenia, Guideline Watch, Assciatin fr Ambulatry Behaviral Healthcare, Standards and Guidelines fr Partial Hspital Prgrams, Behaviral Health Sciences, Medicare and Medicaid, A Review f Evidence Based Practices, Centers fr Medicaid and Medicare Lcal Cverage Determinatin, Psychiatric Inpatient Hspitalizatin, Centers fr Medicaid and Medicare Lcal Cverage Determinatin fr Psychiatric Partial Hspitalizatin Prgram, Current Psychiatry, Differential Diagnsis and Therapeutic Management f Schizaffective Disrder, Ferri, F. Ferri s Clinical Advisr, Disease Overview fr Schizphrenia, Retrieved frm July, Generic UnitedHealthcare Certificate f Cverage, Generic UnitedHealthcare Certificate f Cverage, Generic UnitedHealthcare Certificate f Cverage, Generic UnitedHealthcare Certificate f Cverage, Level f Care Guidelines, Natinal Institute fr Health and Clinical Excellence, Treatment and Management f Schizphrenia in Adults, PORT Psychpharmaclgical Treatment Recmmendatins, Schizphrenia, Substance Abuse and Mental Health Services Administratin, Illness Management and Recvery Practitiner Guide, Substance Abuse and Mental Health Services Administratin, Illness Management and Recvery, Evidence-Based Practices Knwledge Infrming Transfrmatin, Texas Medicatin Algrithm Prject, *Additinal reference materials can be fund in the reference sectin(s) f the applicable Level f Care Guidelines ADDITIONAL RESOURCES Clinical Prtcls Optum maintains clinical prtcls that include the Level f Care Guidelines and Best Practice Guidelines which describe the scientific evidence, prevailing medical standards, and clinical guidelines supprting ur determinatins regarding treatment. These clinical prtcls are available t Cvered Persns upn request, and t Physicians and ther behaviral health care prfessinals n Peer Review Optum will ffer a peer review t the prvider when services d nt appear t cnfrm t this guideline. The purpse f a peer review is t allw the prvider the pprtunity t share additinal r new infrmatin abut the case t assist the Peer Reviewer in making a determinatin including, when necessary, t clarify a diagnsis. Secnd Opinin Evaluatins Optum facilitates btaining a secnd pinin evaluatin when requested by an member, prvider, r when Optum therwise determines that a secnd pinin is necessary t make a determinatin, clarify a diagnsis r imprve treatment planning and care fr the member. Referral Assistance Optum prvides assistance with accessing care when the prvider and/r member determine that there is nt an apprpriate match with the member s clinical needs and gals, r if additinal prviders shuld be invlved in delivering treatment. Schizphrenia & Schizaffective Disrders Page 9 f 10

10 HISTORY/REVISION INFORMATION Date 07/11/2017 Versin 1 Actin/Descriptin Schizphrenia & Schizaffective Disrders Page 10 f 10