OBSESSIVE COMPULSIVE AND HOARDING DISORDER

Optum Cverage Determinatin Guideline OBSESSIVE COMPULSIVE AND HOARDING DISORDER Plicy Number: BH727OCD_102017 Effective Date: Octber, 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 HISTORY/REVISION INFORMATION... 8 Relevant Diagnses: Obsessive Cmpulsive Disrder Harding Disrder Related Clinical Plicies and Guidelines: Obsessive-Cmpulsive Disrder 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 plicy, 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. Obsessive Cmpulsive Disrders Page 1 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

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 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 Obsessive Cmpulsive 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 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) Obsessive Cmpulsive Disrders Page 2 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

CPT Cde Descriptin 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) HCPCS Cde G0177 G0410 G0411 H0004 H0015 H0017 H0018 H0019 H0025 H0035 H2001 H2011 H2012 H2013 H2017 H2018 H2019 H2020 H2033 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 Alchl and/r drug services; intensive utpatient (treatment prgram that perates at least 3 hurs/day and at least 3 days/week and is based n an individualized treatment plan), including assessment, cunseling, crisis interventin, and activity therapy 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 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 Obsessive Cmpulsive Disrders Page 3 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

DSM Classificatin ICD-10 Diagnsis Cde DSM-5 Descriptin 300.3 F42.2 Obsessive Cmpulsive Disrder 300.3 F42.3 Harding Disrder LEVEL OF CARE GUIDELINES Optum / OptumHealth Behaviral Slutins f Califrnia Level f Care Guidelines are available at: 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. Obsessive Cmpulsive Disrders Page 4 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

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: https://www.prviderexpress.cm/cntent/pe-prvexpr/us/en/clinicalresurces/guidelines-plicies/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 B. Screening and Assessment If the standard evaluatin suggests OCD symptms, clinicians shuld cmplete a detailed OCD evaluatin. Special attentin shuld be given t rule ut develpmentally apprpriate behavirs. Initial questins abut the presence f intrusive thughts, images, r urges, repetitive behavirs and mental rituals shuld be asked (Simpsn, 2016). The frequency, amunt f time cnsumed, and extent t which bsessins/cmpulsins cause distress r interfere with his r her life helps t distinguish OCD frm ccasinal intrusive thughts r repetitive behavirs that are cmmn in the general ppulatin. Identifying the main symptm patterns prvides useful infrmatin t infrm treatment and mnitr changes in the severity f the disrder ver time. Identifying a link between bsessins and cmpulsins, and cnfirming that the bsessins lead t anxiety r distress can help t differentiate OCD frm ther disrders f intrusive thughts r repetitive behavirs (Simpsn, 2016). As a part f establishing a diagnsis, measuring the severity f symptms, and measuring the patient s prgress ver time, clinicians may use ne r mre f the fllwing evidence-based tls (AACAP, 2012; APA Guideline Watch, 2013): Yale-Brwn Obsessive Cmpulsive Scale-Revised (Y- BOCS, CY-BOCS fr children). Leytn Obsessinal Inventry (prprietary tl), Anxiety Disrders Interview Schedule (ADIS, ADIS-C fr children). Pediatric Anxiety Rating Scale (PARS fund at http://www.jaacap.cm/). Multidimensinal Anxiety Scale (prprietary tl) (AMAS fr adults, MASC fr children). The Flrida Obsessive-Cmpulsive Inventry symptm checklist and severity scale fr adults. The Obsessive-Cmpulsive Inventry-Revised (OCI-R) fr adults. The scale lks at each subtype (washing, checking, rdering, harding and neutralizing) (prprietary tl). Medical histry t include an inquiry f trauma, neurlgical histry r histry f Pediatric Autimmune Neurpsychiatric Disrders Assciated with Streptcccus (PANDAS) shuld be gathered (AACAP, 2012). Develpmental, academic and/r ccupatinal histry and functining shuld include an assessment f OCD symptms exhibited in the schl setting fr children and adlescents, and in ccupatinal settings in adults (AACAP, 2012). Family functining shuld be assessed t include factrs such as family accmmdatin, enmeshment r negative reinfrcement f OCD behavirs (AACAP, 2012). Educatin shuld be prvided t parents regarding nrmal patterns f develpment and typical behavirs as cmpared t behavir patterns f children with OCD (AACAP, 2012). Obsessive Cmpulsive Disrders Page 5 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

A variety f infrmants shuld be used in evaluating children and adlescents, including parents and teachers (AACAP, 2012). C. Evaluating OCD Symptms in Children and Adlescents Yunger children may exhibit behaviral prblems such as scial withdrawal, aggressive behavir, apathy, sleep disruptin, and weight lss (AACAP, 2012). Adlescents may present with smatic cmplaints, self-esteem prblems, rebelliusness, pr perfrmance in schl, r a pattern f engaging in risky r aggressive behavir (AACAP, 2012). Limited insight and hidden symptms f OCD are frequently prly articulated in yunger children (AACAP, 2012). Cmpulsins withut well-defined bsessins and rituals ften center n the fear f a catastrphic family event (AACAP, 2012). There may nt be a clear precipitating trigger (AACAP, 2012). D. Differential diagnsis The differential diagnsis f OCD rutinely includes ther Anxiety Disrders, Majr Depressive Disrder, Tic Disrder, Psychtic Disrders, and Obsessive-Cmpulsive Persnality disrder. The nature f intrusive thughts and repetitive behavirs can usually distinguish these disrders frm OCD (Simpsn, 2016). The differential diagnsis includes an examinatin f the fllwing cnditins with verlapping symptms prir t cnfirming OCD: Develpmentally apprpriate ritualistic behavirs that may mimic OCD symptms. If these behavirs are present, it may indicate the need fr further parental educatin and/r referral t address any cncerns (AACAP, 2012) Recurrent thughts, avidant behavirs, and repetitive requests fr reassurance ccur in Anxiety Disrders ther than OCD. Distinguishing features f the fllwing Anxiety Disrders can infrm diagnsis (Simpsn, 2015): Recurrent thughts that are present in GAD are usually abut real-life cncerns, while the bsessins in OCD usually are nt. OCD-related cncerns generally invlve cntent that is dd, irratinal, r f a seemingly magical nature. In OCD, cmpulsins are almst always present and usually linked t the bsessins (Simpsn, 2015). Like OCD, Specific Phbias include fear reactins t specific bjects r situatins. Hwever, the feared bjects in Specific Phbia are usually mre circumscribed than thse in OCD, and nt characterized by rituals (Simpsn, 2015). With Scial Anxiety Disrder, feared bjects r situatins are limited t scial interactins r perfrmance situatins. Avidance r reassurance-seeking is fcused n reducing this scial fear (Simpsn, 2015). Symptms f Harding Disrder fcus exclusively n the persistent difficulty f discarding r parting with pssessins, marked distress assciated with discarding items, and excessive accumulatin f bjects. Members wh have bsessins that are typical f OCD (e.g., cncerns abut incmpleteness r harm) that lead t cmpulsive harding behavirs (e.g., acquiring all bjects in a set t attain a sense f cmpleteness r nt discarding ld newspapers because they may cntain infrmatin that culd prevent harm) shuld be diagnsed with OCD (Simpsn, 2015). The ruminative thughts present with MDD are typically md-cngruent and are nt necessarily experienced as intrusive r distressing as in OCD. Ruminatins in depressin are nt linked t cmpulsins as is typical in OCD (Simpsn, 2015). Tic Disrders r Tics are typically less cmplex than cmpulsins and are nt aimed at neutralizing bsessins (Simpsn, 2015). What distinguishes OCD frm a delusinal disrder r psychtic disrder is that thse with OCD have bsessins and cmpulsins, nt ther features such as hallucinatins r disrganized thinking/frmal thught disrder (Simpsn, 2015). Obsessive-Cmpulsive Persnality Disrder invlves an enduring and pervasive maladaptive pattern f excessive perfectinism and rigid cntrl that ften leads t ritualized behavir. OCPD is nt a versin f OCD, and is nt characterized by bsessins. The repetitive behavirs in OCPD are nt perfrmed in respnse t bsessins (Simpsn, 2015). Other disrders that include intrusive thughts and repetitive behavirs can be distinguished frm OCD by the nature f the thughts and behavirs (Simpsn, 2015). In Bdy Dysmrphic Disrder, intrusive thughts are limited t cncerns abut appearance. In Trichtillmania, the repetitive behavir is limited t hair-pulling. In Anrexia Nervsa, intrusive thughts and repetitive behavirs are limited t cncerns abut weight and fd. Other behavirs that are smetimes cnsidered cmpulsive, include sexual behavir, gambling, and substance use (Simpsn, 2015). Obsessive Cmpulsive Disrders Page 6 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

E. Evaluatin f Harding Symptms As a part f establishing the diagnsis, measuring the severity f symptms may include the use ne r mre f the fllwing evidence-based tls (American Psychiatric Assciatin, Obsessive Cmpulsive Disrder, Guideline Watch (APA Watch), 2013): The Saving Inventry-Revised (SI-R) scale Harding Rating Scale (HRS-SR) Self-reprt measure Harding Rating Scale Interview: In rder t establish a Harding Disrder diagnsis, the clinician shuld gather infrmatin abut the fllwing (Saxena & Maidment, Treatment f Cmpulsive Harding, Fcus, 2007, retrieved frm psychiatrynline.rg): Amunt f clutter and whether it extends beynd the member s hme (e.g., cars, garage, strage areas); and if the clutter impacts nrmal activities (e.g., sleeping in a bed, sitting n cuches r using the kitchen cunter). Beliefs abut pssessins and whether the member feels respnsible fr pssessins, feels that each item has a special significance, r ges t great lengths t avid wastefulness. Decisin making abut and categrizatin f pssessins and whether there is distractibility and difficulty maintaining attentin n tasks. Avidance behavirs and whether cmpleting daily rutines and tasks t maintain rder is pssible (e.g., srting mail, returning calls, washing dishes). Daily functining and whether it is disrupted by ruminating abut perfectin r mving items frm ne pile t anther withut accmplishing a desired task. Cmpliance with medical care and whether the member is taking prescribed medicatins if applicable, and keeping up with medical appintments. Level f insight and whether there is awareness f ne s wn harding, clutter and hw this impacts the member s life. Scial and ccupatinal functining and whether the member has family r scial supprt r if their harding has them scially islated. Wrk perfrmance may als be impaired. Baseline phtgraphs f their cluttered areas. Differential Diagnsis: In rder t establish a Harding Disrder diagnsis, the fllwing cnditins shuld be ruled ut: OCD shuld be assigned when the symptms are judged t be a direct cnsequence f typical bsessins r cmpulsins (e.g., fears f cntaminatin, Psychtic Disrders and symptms (e.g., Schizphrenia, intrusive thughts, ruminatins). F. 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/clinicalresurces/guidelines-plicies/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 G. Psychscial Interventins Cgnitive Behaviral Therapy with Expsure and Respnse Preventin (CBT-ERP) is a first line interventin with r withut medicatin (APA Watch, 2013). CBT fr OCD typically includes: patient and family educatin, cgnitive restructuring, expsure therapy, and respnse preventin (Abramwitz, 2016). The use f CBT-ERP rather than medicatin as a first-line treatment is typically recmmended fr members with nn- cmrbid OCD. An SSRI can be used fr members wh prefer medicatin t psychtherapy, r when CBT is nt available (Simpsn, 2016). Prir t beginning psychtherapy, the member shuld be prvided with educatin regarding OCD and given a clear explanatin as t hw CBT-ERP is expected t be helpful in reducing OCD. Such educatin is an imprtant first step in therapy t mtivate the patient t tlerate the distress that typically accmpanies expsure practice (Simpsn, 2016). CBT-ERP treatment seeks t strategically increase symptms f anxiety thrugh expsure while preventing avidance, distractin, and rituals as ways f cping with the anxiety. This apprach creates the pprtunity fr habituatin t anxiety- inducing situatins that impact the patient s OCD symptms (APA, 2007). CBT-ERP treatment cmpnents include (APA, 2007): A detailed assessment f the individual s fears, avidances, and rituals which demnstrates the OCD symptm pattern; Develpment f an expsure hierarchy rating scale f feared r avided items r thughts (0-100 based n level f discmfrt); Obsessive Cmpulsive Disrders Page 7 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

Develpment f a respnse preventin plan detailing hw t prevent engaging in rituals (behaviral r cgnitive) and a frm f self-mnitring f rituals by the patient t be prvided t the clinician t help assess prgress and t further identify triggers; In viv expsure r direct expsure f the patient t the feared item, situatin, r thughts frm the hierarchy, steadily prgressing frm lwer t higher rated items. A 13-20 week trial f weekly utpatient sessins is recmmended, and an evaluatin f the member s respnse with the use f measurement tls shuld be cmpleted. The Y-BOCS shuld be used t measure and re-measure OCD symptms after an initial trial f psychtherapy has been cmpleted (Siebell and Hllander, 2014). If there has been an adequate respnse, the clinician shuld prvide mnthly utpatient bster sessins fr 3-6 mnths r mre frequently if there is a partial respnse (APA, 2007). If respnse t CBT-ERP is clinically significant but inadequate (i.e., mderate respnse) r clinically insignificant and inadequate (i.e., little r n respnse), secnd trial treatments shuld be initiated (APA, 2007). Fr OCD Prlnged Expsure Therapy is ften indicated when the member requires therapist-guided repeated and prlnged expsure t situatins that prvke bsessinal fear alng with abstinence frm cmpulsive behavirs (respnse preventin). This might ccur in the frm f repeated actual cnfrntatin with feared lw-risk situatins, r in the frm f imaginal cnfrntatin with the feared disastrus cnsequences f cnfrnting the lw-risk situatins (Abramwitz, 2015). PE may be indicated fr OCD fr up t 16 twice- weekly treatment sessins, lasting abut 90 t 120 minutes each, ver abut eight weeks (Abramwitz, 2016). Adjunctive interventins may be initiated that d nt address the cre symptms f OCD but may be useful in addressing acceptance, resistance r the interpersnal cnsequences f OCD. Examples include (APA, 2007): Mtivatinal Interviewing; and Family therapy t reduce intra-familial tensins that may be exacerbating symptms. Cmbinatin psychtherapy and pharmactherapy is recmmended fr children and adlescents (AACAP, 2012). The first line treatment fr Harding Disrder is Cgnitive Behavir Therapy that incrprates Expsure Respnse Preventin (ERP) and addresses the fllwing (Saxena & Maidment, 2007): Triggers assciated with harding; Infrmatin prcessing deficits; Prblems in frming emtinal attachments; Behaviral avidance; Errneus beliefs abut the nature f pssessins; Decisin-making and cping skills; Urges t save; De-cluttering via ERP in the fllwing steps: Discarding Organizing Preventing incming clutter Intrducing alternative behavirs Ending treatment CBT-ERP may include family, grup and hme sessins; Peridic therapy bster sessins t maintain prgress. Duratin f treatment fr Harding Disrder may be up t ne year with the invlvement f family members and mtivatinal enhancement techniques t prmte prgress and reduce the risk f relapse. H. General Pharmactherapy SSRIs (with the exceptin f citalpram & escitalpram) r clmipramine alne r with CBT-ERP are first line treatments fr adults with cmrbid OCD (APA Watch, 2013). Mst members receiving utpatient treatment will require treatment fr 6-12 weeks t experience imprvement (APA Watch, 2013). Higher dses f antidepressants have generally been fund t be mre effective fr OCD. Fr example, fluxetine can be gradually titrated t 40 t 80 mg/day. The medicatin shuld be cntinued within the therapeutic range fr at least six weeks befre cncluding that the drug is ineffective (Simpsn, 2016). If there is adequate respnse t utpatient treatment, pharmactherapy shuld be cntinued fr 1-2 years then gradually tapered (APA, 2007). If there is n respnse t a mderate respnse, secnd trial treatments shuld be initiated (APA, 2007). Cnsideratins when chsing the mst apprpriate agent include (APA, 2007): Age f the patient Previus treatment respnse Risk f verdse r misuse Obsessive Cmpulsive Disrders Page 8 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

Tlerability Interactins and side effects Secnd Trial If there is little r n respnse t CBT-ERP treatment nly, r a mderate respnse, add a SSRI (APA, 2007). If there is little r n respnse t a SSRI, cnsider any f the fllwing (APA, 2007): Switch t a different SSRI, clmipramine, r venlafaxine. Augment SSRI with aripiprazle r risperidne (Guideline Watch, 2013). If there is a mderate respnse t a SSRI, cnsider any f the fllwing: Augment SSRI with aripiprazle r risperidne (Guideline Watch, 2013). If respnse t Secnd Trial is mderate, third trial treatments are indicated. Third Trial If respnse t secnd trial is mderate, cnsider either f the fllwing: Switch t a different augmenting antipsychtic (aripiprazle r risperidne) (Guideline Watch, 2013). Switch t a different SSRI (APA, 2007). Pharmactherapy recmmendatins are the same fr adults and children with the fllwing specific recmmendatins fr children/adlescents with OCD: 14 utpatient visits ver 12 weeks that spread acrss 5 phases. With the exceptin f weeks 1 and 2, all utpatient visits are weekly. The phases include (AACAP, 2012): Psycheducatin; Cgnitive Training; Mapping OCD; Expsure and Respnse Preventin (E/RP); and Relapse Preventin and Generalizatin Training. If there has been n respnse t CBT interventins after 8-10 sessins r 6-8 E/RP sessins, implement secnd trial recmmendatins (AACAP, 2012). Titratin schedules shuld be cnservative; with mdest increases frm initial dse each three weeks t allw fr imprvement t manifest befre increasing dses (AACAP, 2012). Treatment is generally cntinued fr 6-12 mnths fllwing initial stabilizatin and then very gradually withdrawn ver several mnths (AACAP, 2012). As a secnd-line r cmbinatin treatment with CBT, SSRI medicatins may be prescribed althugh patients with harding behavirs typically have a pr respnse rate t SSRI medicatins (Saxena & Maidment, 2007). I. 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/clinicalresurces/guidelines-plicies/lcg.html REFERENCES* Abramwitz, J. (2016). Psychtherapy fr Obsessive Cmpulsive Disrder in Adults. Retrieved frm www.uptdate.cm. American Academy f Child and Adlescent Psychiatry, Practice Parameter fr the Assessment and Treatment f Children and Adlescents with Obsessive Cmpulsive Disrder, 2012. American Psychiatric Assciatin Diagnstic and Statistical Manual f Mental Disrders, Furth Editin, Text Revisin, 2000. American Psychiatric Assciatin, Practice Guideline fr the Treatment f Patients with Obsessive Cmpulsive Disrder, 2007. American Psychiatric Assciatin, Guideline Watch fr the Treatment f Patients with Obsessive Cmpulsive Disrder, March, 2013. Assciatin fr Ambulatry Behaviral Healthcare, Standards and Guidelines fr Partial Hspital Prgrams, 2008. Center fr Medicaid and Medicare Lcal Cverage Determinatin, Psychiatric Inpatient Hspitalizatin, 2012. http://www.cms.gv/medicare-cverage- database/indexes/lcd-alphabetical-index.aspx?bc=agaaaaaaaaaa& Center fr Medicaid and Medicare Lcal Cverage Determinatin fr Psychiatric Partial Hspitalizatin Prgram, 2013. http://www.cms.gv/medicare-cverage-database/indexes/lcd-alphabetical- index.aspx?bc=agaaaaaaaaaa& Generic UnitedHealthcare Certificate f Cverage, 2001. Generic UnitedHealthcare Certificate f Cverage, 2007. Obsessive Cmpulsive Disrders Page 9 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.

Generic UnitedHealthcare Certificate f Cverage, 2009. Generic UnitedHealthcare Certificate f Cverage, 2011. Optum Level f Care Guidelines, 2015. Saxena & Maidment, Treatment f Cmpulsive Harding, Fcus, 2007, retrieved frm psychiatrynline.rg, May, 2014. Siebell, P. and Hllander, E. (2014). Management f Obsessive Cmpulsive Disrder. Retrieved frm Natinal Institutes f Health, www.ncbi.nlm.nih.gv/pmc/articles/pmc4126524. Simpsn, Stein & Hermann, Obsessive-cmpulsive disrder in adults: Epidemilgy, pathgenesis, clinical manifestatins, curse, and diagnsis, retrieved frm www.uptdate.cm, May, 2014. Simpsn, H.B., Obsessive-cmpulsive disrder in adults: Epidemilgy, pathgenesis, clinical manifestatins, curse, and diagnsis. Retrieved frm www.uptdate.cm, May, 2015. *Additinal reference materials can be fund in the reference sectin(s) f the applicable Level f Care Guidelines HISTORY/REVISION INFORMATION Date 02/14/2017 Versin 1 10/10;2017 Versin 2- Annual Update Actin/Descriptin Obsessive Cmpulsive Disrders Page 10 f 10 Optum Cverage Determinatin Guideline Effective Octber, 2017 Prprietary Infrmatin f Optum. Cpyright 2017 Optum, Inc.