OTHER AND UNSPECIFIED DISORDERS

OPTUM COVERAGE DETERMINATION GUIDELINE OTHER AND UNSPECIFIED DISORDERS Guideline Number: BH727OUD_102017 Effective Date: Octber, 2017 Table f Cntents Page INSTRUCTIONS FOR USE... 1 BENEFIT CONSIDERATIONS... 1 COVERAGE RATIONALE... 2 APPLICABLE CODES... 3 LEVEL OF CARE GUIDELINES... 4 UNITEDHEALTHCARE BENEFIT PLAN DEFINITIONS... 4 EVIDENCE-BASED CLINICAL GUIDELINES... 5 REFERENCES... 7 ADDITIONAL RESOURCES... 7 HISTORY/REVISION INFORMATION... 7 Relevant Diagnses: N/A Related Clinical Plicies & Guidelines: Other Specified and Unspecified Disrders 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 guideline, 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, hme-based 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 Other and Unspecified Disrders Page 1 f 7

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 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 guideline, it is imprtant t refer t the member-specific benefit dcument t determine benefit cverage. COVERAGE RATIONALE Effective and efficient treatment is facilitated by the clarity and accuracy f the diagnsis. An Other Specified r Unspecified diagnsis is used when a cmprehensive evaluatin and further diagnstic specificity is nt pssible. Clinicians assign these diagnses when there are diagnstic features f a disrder within a diagnstic class but the presenting signs, symptms and features d nt meet the full criteria fr a specific disrder. The Other Specified Disrder categry allws the clinician t cmmunicate the specific reasn that the presentatin des nt meet the criteria fr any specific categry within a diagnstic class. This is dne by recrding the name f the categry, fllwed by the specific reasn (Diagnstic and Statistical Manual f Mental Disrders, 5th ed.; DSM-5; American Psychiatric Assciatin, p.15, 2013). The fllwing is an example f Other and Unspecified Disrders: A member has clinically significant depressive symptms lasting 4 weeks but symptmtlgy falls shrt f the diagnstic threshld fr a majr depressive episde, then the clinician wuld recrd Other Specified Depressive Disrder, depressive episde with insufficient symptms (DSM-5, p. 15, 2013). The use f the Unspecified Disrder in the current editin f the Diagnstic and Statistical Manual f the American Psychiatric Assciatin is excluded. It is given when the clinician des nt specify the reasn that the criteria are nt met within a diagnstic class. (DSM-5, p. 16, 2013). The fllwing is an example f a circumstance under which mental health treatment fr Other and Unspecified Disrders are excluded: In an emergency department setting, nly the mst prminent symptm expressins assciated with a particular categry are identified (e.g., delusins, hallucinatins, mania, depressin, anxiety, r substance intxicatin) rather than assigning the Other Specified Disrder (DSM-5, p. 20). Benefits are available fr cvered services that are nt therwise limited r excluded. Services shuld be cnsistent with evidence-based interventins and clinical best practices as described in Part III, and shuld be f sufficient intensity t address the member's needs (Certificate f Cverage, 2007, 2009 & 2011). 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 Other and Unspecified Disrders Page 2 f 7

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 Cverage Determinatin Guidelines may apply. CPT Cde Descriptin 90785 Interactive cmplexity (list separately in additin t the cde fr primary prcedure) 90791 Psychiatric diagnstic evaluatin 90792 Psychiatric diagnstic evaluatin with medical services 90832 Psychtherapy, 30 minutes with patient and/r family member Psychtherapy, 30 minutes with patient and/r family member when perfrmed with 90833 an evaluatin and management service(list separately in additin t the cde fr primary prcedure) 90834 Psychtherapy, 45 minutes with patient and/r family member 90836 Psychtherapy, 45 minutes with patient and/r family member when perfrmed with an evaluatin and management service (list separately in additin t the cde fr primary prcedure) 90837 Psychtherapy, 60 minutes with patient and/r family member 90838 Psychtherapy, 60 minutes with patient and/r family member when perfrmed with an evaluatin and management service (list separately in additin t the cde fr primary prcedure) 90839 Psychtherapy fr crisis; first 60 minutes 90840 Psychtherapy fr crisis; each additinal 30 minutes (list separately in additin t the cde fr primary service) 90846 Family psychtherapy (withut the patient present) 90847 Family psychtherapy (cnjint psychtherapy) (with the patient present) 90849 Multiple-family grup psychtherapy 90853 Grup psychtherapy (ther than f a multiple-family grup) 90863 Pharmaclgic management, including prescriptin and review f medicatin, when perfrmed with psychtherapy services (List separately in additin t the cde fr primary prcedure) CPT is a registered trademark f the American Medical Assciatin HCPCS Cde G0177 G0410 G0411 H0004 H0017 H0018 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 Other and Unspecified Disrders Page 3 f 7

HCPCS Cde H0019 H0025 H0035 H2001 H2011 H2012 H2013 H2017 H2018 H2019 H2020 H2033 S0201 S9480 S9482 S9484 S9485 Descriptin 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 Behaviral health preventin educatin service (delivery f services with target ppulatin t affect knwledge, attitude and/r behavir) 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 Multisystemic therapy fr juveniles, per 15 minutes Partial hspitalizatin services, less than 24 hurs 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 DSM Classificatin ICD-10 Diagnsis Cde Descriptin N/A F20.9 Schizphrenia, unspecified F25.9 Schizaffective disrder, unspecified F30.9 Manic episde, unspecified F31.89 Other biplar disrder F32.89 Other specified depressive episdes F32.9 Majr depressive disrder, single episde, unspecified F33.9 Majr depressive disrder, recurrent, unspecified F39 Unspecified md (affective) disrder F40.9 Phbic anxiety disrder, unspecified F41.8 Other specified anxiety disrder F42.9 Obsessive-cmpulsive disrder, unspecified F43.10 Pst-traumatic disrder, unspecified F43.20 Adjustment disrder, unspecified F43.9 Reactin t severe stress, unspecified F44.9 Dissciative and cnversin disrder, unspecified F45.20 Hypchndriacal disrder, unspecified F45.9 Smatfrm disrder, unspecified F48.8 Other specified nnpsychtic mental disrders F48.9 Nnpsychtic mental disrder, unspecified F50.89 Other specified eating disrder F50.9 Eating disrder, unspecified F90.9 Attentin-deficit hyperactivity disrder, unspecified type LEVEL OF CARE GUIDELINES Optum / OptumHealth Behaviral Slutins f Califrnia Level f Care Guidelines are available at: Other and Unspecified Disrders Page 4 f 7

https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinical-resurces/guidelinesplicies/lcg.html 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. 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. Other and Unspecified Disrders Page 5 f 7

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: https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinical-resurces/guidelinesplicies/lcg.html Optum recgnizes the American Psychiatric Assciatin s Practice Guidelines fr the Psychiatric Evaluatin f Adults (2016): http://www.psychiatry.rg > Psychiatrists > Practice > Clinical Practice Guidelines When establishing a diagnsis, cnsider the fllwing: An Other Specified r Unspecified diagnsis is nt the same as a prvisinal diagnsis. A prvisinal diagnsis (a.k.a. wrking diagnsis ) is given when there is limited infrmatin that prevents a clinician frm establishing a firm principal DSM diagnsis. A prvisinal diagnsis is applied when: There is a strng presumptin that the full criteria f a DSM classified disrder will ultimately be met, but nt enugh infrmatin is available t make a firm diagnsis (i.e., a full histry is needed t establish if full criteria are met) (DSM-5, p. 23, 2013). Differential diagnsis is dependent exclusively n the duratin f the illness (i.e., remissin cannt be cnfirmed until 6 mnths has lapsed) (DSM-5, p. 23, 2013). Carefully differentiate symptms that supprt an Other Specified r Unspecified diagnsis frm thse that: Supprt a prvisinal diagnsis ; r Meet the full criteria fr a specific disrder. Further assessment shuld cnfirm whether the member s symptms cntinue t warrant an Other Specified r Unspecified diagnsis (e.g., there, is uncertainty abut whether the symptms are substance induced r due t a general medical cnditin, there is insufficient pprtunity t cmplete data cllectin, r there is incnsistent r cntradictry infrmatin). Cverage fr an Other Specified may be indicated when: The member s diagnsis meets the DSM definitin f a Other Specified Disrder r Unspecified Disrder ; The member s diagnsis des nt meet the full criteria fr a specific disrder; There will be further assessment t cnfirm whether the member s symptms cntinue t warrant an Other Specified diagnsis due t: Uncertainty abut whether the symptms are substance induced r due t a general medical cnditin, Insufficient pprtunity t cmplete data cllectin, r Incnsistent r cntradictry infrmatin. Cverage fr Other Specified may be reviewed against the Cverage Determinatin Guideline f the specific cnditin that cincides with the Other Specified (e.g., Majr Depressive Disrder will be used t review a diagnsis f Other Specified Depressive Disrder ). When treating an Other Specified r Unspecified disrder, cnsider using evidence-based practices which are recmmended fr the specific cnditin which is mst like the Other Specified r Unspecified disrder. B. Treatment planning cmmn criteria and best practices See Cmmn Criteria and Best Practices fr All Levels f Care, available at: https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinical-resurces/guidelinesplicies/lcg.html Optum recgnizes the American Psychiatric Assciatin s Practice Guidelines fr the Psychiatric Evaluatin f Adults (2016): http://www.psychiatry.rg > Psychiatrists > Practice > Clinical Practice Guidelines Other and Unspecified Disrders Page 6 f 7

The fllwing are examples f services that are incnsistent with the Level f Care Guidelines and Best Practice Guidelines (nt an all-inclusive list): Services that deviate frm the indicatins fr cverage summarized in this dcument. The use f Other Specified when the presenting signs, symptms and functinal impairments demnstrate evidence t supprt the full criteria f a DSM classified cnditin. The use f an Other Specified diagnsis when a prvisinal diagnsis is mre apprpriate. Use f an Other Specified diagnsis when all general medical cnditins and substance induced cnditins have nt been ruled ut. Use f an Other Specified diagnsis when there has been sufficient pprtunity t gather data r clarify incnsistent r cntradictry infrmatin. C. Discharge planning cmmn criteria and best practices see Cmmn Criteria and Best Practices fr All Levels f Care : https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinical-resurces/guidelinesplicies/lcg.html REFERENCES* American Psychiatric Assciatin. Diagnstic and statistical manual f mental disrders (5 th ed.) 2013; Arlingtn, VA: American Psychiatric Publishing. Generic UnitedHealthcare Certificate f Cverage, 2001 Generic UnitedHealthcare Certificate f Cverage, 2007 Generic UnitedHealthcare Certificate f Cverage, 2009 Generic UnitedHealthcare Certificate f Cverage, 2011 Generic UnitedHealthcare Certificate f Cverage, 2017 *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 www.prviderexpress.cm. 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 then 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. HISTORY/REVISION INFORMATION Date 10/01/2016 Versin 1 10/10/2017 Versin 2 Annual Review Actin/Descriptin Other and Unspecified Disrders Page 7 f 7