Medical Plicy MP 3.01.501 Guidelines fr Cverage f Mental and Behaviral Health Services Last Review: 8/30/2017 Effective Date: 8/30/2017 Sectin: Mental Health End Date: 08/19/2018 Related Plicies Nne DISCLAIMER Our medical plicies are designed fr infrmatinal purpses nly and are nt an authrizatin, explanatin f benefits r a cntract. Receipt f benefits is subject t satisfactin f all terms and cnditins f the cverage. Medical technlgy is cnstantly changing, and we reserve the right t review and update ur plicies peridically. POLICY Definitins f Medically Necessary and Investigatinal cntained in this plicy may nt apply t sme health plans, such as Federal Emplyee Prgram (FEP), Medicare Advantage and sme self-funded grup plans. Blue Crss f Idah reserves the right t peridically update definitins. COVERED SERVICES MAY BE REVIEWED FOR MEDICAL NECESSITY Blue Crss f Idah may review services fr which cverage is being requested at any time accrding t standards f quality, apprpriateness, adherence t best practices, and medical necessity. MEDICALLY NECESSARY The Cvered Services r supplies required t identify r treat an Insured s cnditin, Disease, Illness r Accidental Injury and which, as recmmended by the treating Physician r ther Cvered Prvider and as determined by Blue Crss f Idah, are: The mst apprpriate supply r level f service, cnsidering ptential benefits and harms t the Insured. Prven t be effective in imprving health utcmes; Fr new treatments, effectiveness is determined by scientific evidence; Fr existing treatments, effectiveness is determined first by scientific evidence, then by prfessinal standards, then by expert pinin. Nt primarily fr the cnvenience f the Insured r Cvered Prvider. Cst-effective fr this cnditin, cmpared t alternative treatments, including n treatment. Cst-effectiveness des nt necessarily mean lwest price. Services and treatments deemed investigatinal accrding t the fllwing criteria will be denied as such. INVESTIGATIONAL Any technlgy (service, supply, prcedure, treatment, drug, device, facility, equipment r bilgical
Guidelines fr Cverage f Mental and Behaviral Health Services prduct), which is in a develpmental stage r has nt been prven t imprve health utcmes such as length f life, quality f life, and functinal ability. A technlgy is cnsidered investigatinal if, as determined by Blue Crss f Idah, it fails t meet any ne f the fllwing criteria: The technlgy must have final apprval frm the apprpriate gvernment regulatry bdy. This applies t drugs, bilgical prducts, devices, and ther prducts/prcedures that must have apprval frm the U.S. Fd and Drug Administratin (FDA) r anther federal authrity befre they can be marketed. Interim apprval is nt sufficient. The cnditin fr which the technlgy is apprved must be the same as that BCI is evaluating. The scientific evidence must permit cnclusins cncerning the effect f the technlgy n health utcmes. The evidence shuld cnsist f current published medical literature and investigatins published in peer-reviewed jurnals. The quality f the studies and cnsistency f results will be cnsidered. The evidence shuld demnstrate that the technlgy can measure r alter physilgical changes related t a Disease, injury, Illness, r cnditin. In additin, there shuld be evidence that such measurement r alteratin affects health utcmes. The technlgy must imprve the net health utcme. The technlgy s beneficial effects n health utcmes shuld utweigh any harmful effects n health utcmes. The technlgy must be as beneficial as any established alternatives. The technlgy must shw imprvement that is attainable utside the investigatinal setting. Imprvements must be demnstrated when used under the usual cnditins f medical practice. Requests fr Mental and Behaviral Health Services will be reviewed accrding t established criteria. Requests nt meeting these criteria will be denied as nt medically necessary and thus nt eligible fr cverage. Criteria and resurces used in cverage determinatins may include but are nt limited t: 1. Blue Crss f Idah Medical Plicies 2. McKessn InterQual criteria 3. American Psychiatric Assciatin Standards and Guidelines 4. American Sciety f Addictin Medicine Standards and Guidelines 5. Current published medical literature and peer reviewed publicatins based upn scientific evidence 6. Other evidence-based standards and guidelines, as apprpriate DOCUMENTATION REQUIRED FOR REVIEW OF MEDICAL NECESSITY In rder t review cverage requests fr Mental and Behaviral Health Services, the fllwing clinical dcumentatin frm the treating mental health prfessinal may be required: 1. Diagnsis 2. Treatment histry 3. Current symptms including cmplete prblem list 4. Dcumentatin as t what factrs necessitate treatment at this time 5. Results f measurement tls utilized t quantify symptm severity and prgressin 6. Current functinal limitatins as cmpared t pre-mrbid functinality 7. Individualized treatment plan using established, evidence-based mdalities 8. Specific, measurable, time-limited treatment gals 9. Barriers t treatment 10. Respnse t current and previus treatments 11. Fr nging services, dcumentatin f quantitative measures f imprvement as a result f services up t that pint Original Plicy Date: Octber 2015 Page: 2
Guidelines fr Cverage f Mental and Behaviral Health Services 12. Anticipated treatment duratin 13. Plan fr discharge frm the requested level f care 14. Plan fr develping cping strategies and a supprt system that will help the member be successful upn discharge frm the requested level f care OUTPATIENT PSYCHOTHERAPY SERVICES Outpatient psychtherapy n lnger requires prir authrizatin. Instead Blue Crss f Idah will cnduct audits based n submitted claims. Criteria used t select cases fr audit include, but are nt limited t, the fllwing: 1. High utilizatin (utpatient psychtherapy spanning mre than 12 cnsecutive mnths) and/r frequency (three r mre psychtherapy sessins per week) 2. Diagnsis persisting lnger than DSM-5 guidelines (primarily nn-chrnic diagnses fr mre than six cnsecutive mnths) 3. Multiple practitiners billing psychtherapy sessins 4. Multiple hspitalizatins while receiving psychtherapy services (three r mre in ne year) 5. Refer t PAP 902 fr audit details LEVELS OF TREATMENT The fllwing levels f service may be cvered when cntractual and medical necessity requirements are fulfilled. Services that d nt meet the requirements fr the requested level f treatment accrding t the criteria abve will be denied as nt medically necessary. Intensive Outpatient Prgram (IOP) Partial Hspitalizatin Prgram (PHP) Residential Treatment Centers (RTC) Psychiatric Hspitalizatin Outpatient Services Psychtherapy Psychlgical and Neurpsychlgical Testing Electrcnvulsive Therapy (ECT) Transcranial Magnetic Stimulatin (TMS) See MP 2.01.550 NON-COVERED OR NOT MEDICALLY NECESSARY SERVICES The fllwing mental health services may be specifically excluded frm cverage under the terms f the member s cntract. In such cases, they will be denied as a cntract-exclusin. When they are nt explicitly identified in the member cntract, they may be denied as nt medically necessary as defined abve: Therapies nt based n American Psychiatric and American Psychlgical Assciatin acceptable techniques and theries; Vcatinal r religius cunseling; Cnsciusness raising; Testing r treatment fr learning disabilities; Activities primarily f an educatinal nature; Original Plicy Date: Octber 2015 Page: 3
Guidelines fr Cverage f Mental and Behaviral Health Services Marriage cunseling; Services fr scial maladjustment, lack f discipline, r ther antiscial actins which are nt specifically the result f mental illness; Assertiveness training; Cgnitive training; Primal therapy; Bienergetic therapy; Obesity cntrl therapy; Sleep therapy; Dance therapy; Music r art therapy; IQ testing, except as a cmpnent f individualized, medically necessary psychlgical/neurpsychlgical evaluatin; Scializatin, delinquency r custdial care services; Stress reductin classes; Pastral cunseling; Acupuncture, acupressure r massage therapy, Rlfing, hmepathic r naturpathic remedies; Self-care r self-help training; Inpatient cnfinement fr envirnmental change r similar treatment; Dream therapy; Recreatinal therapy; Equine r ther animal therapy; Wilderness prgrams; Adventure therapy; Bright light therapy; Any ther techniques which are nt supprted by scientific evidence and the medical necessity criteria, as defined abve. POLICY HISTORY Date Actin Reasn 10/22/15 New plicy Blue Crss f Idah lcal plicy added t utline cvered services versus nn-cvered services. 10/19/16 Replace plicy Blue Crss f Idah annual review, n change t plicy. 08/30/17 Replace plicy Plicy revised t remve link t PAP 909; remved Outpatient Psychtherapy Services cverage criteria f practice patterns abve the 95th percentile (i.e., 20 sessins r less fr nn-chrnic psychiatric diagnses and 30 sessins r less fr psychiatric diagnsis. Added high utilizatin, persistent diagnsis, multiple practitiners, multiple hspitalizatins, with specific criteria and reference t PAP 902. Original Plicy Date: Octber 2015 Page: 4
Guidelines fr Cverage f Mental and Behaviral Health Services 04/30/18 Update nly Medical plicy renumbered frm 3.01.01 t 3.01.501. Original Plicy Date: Octber 2015 Page: 5