Skip to Main Content

Section 9: Level of Care Criteria & Medical Necessity

9.1 Level of Care Criteria

1. Adult Psychiatric Home Care

Effective Date: 11/14/2001
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Definition:

Psychiatric home care is treatment that is delivered away from a professional office or institution, usually at patient's home. This may be needed in circumstances when patient is homebound and/or unable to ambulate. The service must be provided by a mental health professional. The type of treatment, its intensity and duration varies according to medical necessity.

Comments:

This type of care is an interim treatment that arises from the situations in which patient is unable to pursue care at the provider's office site, and is generally time-limited. It is a general expectation that patient will continue to attend treatment at the provider's office as soon as the physical or emotional limitations have been removed.

Admission Criteria - Requires ALL:

Patient will have a DSM diagnosis. Patient will benefit greatly from the home care treatment, that otherwise will not be accessible due to severe psychological or physical obstacles, preventing patient from coming to provider's office. Family/significant others if available can provide adequate support and will be involved in the treatment process. There is evidence of sufficient motivation for successful engagement in treatment at this level of care.

Continuing Stay Criteria - Requires ALL:

Patient must have a DSM diagnosis. Patient continues to be unable to travel to provider's office due to debilitating psychological or physical illness and will benefit from treatment at this level of care. Pt will build adequate coping skills to handle triggers and stress. Clinical evidence suggests that treatment at this level of care is needed to foster the development and/or involvement of a support system.

4. There is evidence of clear progress achieved in treatment at this level of care.

Comment:

Relapse, worsening of the clinical symptoms or refusal to attend to treatment on one or more occasions should trigger a review by Medical Director.

Discharge Criteria - Requires ONE:

The patient has either reached a level of functioning permitting the continuation of treatment in a professional office or has reached full remission of psychiatric illness. Family/significant others if available can provide adequate support.

The probability of successful outcome with continued treatment at this level is seriously compromised because patient and/or family or significant others are non-compliant with treatment recommendations. Examples may include but are not limited to: active substance abuse, refusing medications or psychiatric consultation when clinically indicated, failure to readily engage in the treatment process. There is little evidence that intervention thus far has improved compliance. There is little evidence that the current treatment plan is effective.

There is no alternate appropriate treatment plan proposed. Further progress is deemed unlikely at this level.

1. Adolescent Residential Subacute Detox Criteria

Effective Date: 05/08/2015
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Definition:

Subacute Detoxification is an appropriately licensed organized freestanding service that may be delivered by appropriately trained staff, which provides 24-hour supervision, observation and support for adolescent patients who are experiencing withdrawal or evidence of impending withdrawal. However, the full resources of a medically monitored inpatient detoxification service are not necessary. 1 Other forms of Subacute Detoxification include Ambulatory Detox as in ASAM 1D and 2D, and are covered under the InterQual Level of Care guidelines. Subacute residential detoxification is generally characterized by its emphasis on peer and social support. This is a Social Model Program (corresponding to ASAM level III.1 only). Placement in a Social Model Program should occur only after evaluation has been done by a physician (preferably by a Psychiatrist or Addictionologist) to assess for medical stability and for the presence of Co-Morbid Mental Illness. This level of care is provided only to patients who have a DSM 5 diagnosis of Substance Use Disorder and their substance use has caused a significant impairment in their level of social and/or occupational functioning. Patients who are in late stages of detoxification and are not at risk for further physiological deterioration are considered sufficiently medically stable for treatment at this level of care.

Comments:

  1. A residential Adolescent Subacute Detoxification Program must meet the following criteria:
    1. Program needs to have established clinical protocols to identify adolescent patients (ages 13-17) who are in need of medical services beyond the capacity of the facility and to transfer such patients to more appropriate levels of care. 
    2. Program needs to be able to arrange for appropriate laboratory and toxicology tests 
    3. Program is staffed by appropriately credentialed personnel who is trained and competent to implement physician-approved protocols for patient observation and supervision
    4. Program is designed explicitly to safely detoxify patients without the need for ready on-site access to medical personal 
    5. Medical evaluation and consultation is available 24 hours a day 
    6. All clinicians who assess and treat patients are able to obtain and interpret information regarding the needs of the patients. This includes knowledge of: 
      1. Signs and symptoms of alcohol and other drug intoxication and withdrawal states 
      2. Appropriate treatment and monitoring of these intoxication or withdrawal states 
    7. Facilities that supervise self-administered medications have appropriately licensed or credentialed staff and policies and procedures accordance with state and federal law 
    8. Staff ensure that the patients are taking medications according to physician prescription and legal requirements 
    9. Program provides daily clinical services to assess and address needs of each patient including medical services, individual and group therapies, and withdrawal support 
  2. The following guidelines are suggested for an individualized Substance Use Disorder Subacute Detoxification treatment plan as clinically indicated: 
    1. Individual counseling daily. 
    2. Group counseling daily. 
    3. Family psychotherapy 1- 2X/week. 
    4. Milieu therapy daily. 
    5. Substance Use Disorder - 12-step group daily. 
    6. Medication management (when indicated) at least 1X/wk.
  3. If clinical presentation suggests that intensive family intervention is critical, then patient should be referred to the closest geographical facility to their home. This would facilitate and smooth transition to lower levels of care and aftercare.

Admission Criteria:

Severity of Illness (SI)

Section A. Must satisfy ALL of the following criteria:

  1. The nature and pattern of use of abused substances (including frequency and duration) predicts withdrawal potential, however, the patient is at minimal risk of medically-complicated withdrawal and there is little chance that withdrawal from psychoactive substances could potentially be life threatening. 
  2. There is minimal risk that the patient's medical condition(s) or the presence of medical complications places the patient in imminent danger of serious health risk and they can be managed at a Subacute Detoxification Level of Care. If there is a medical condition requiring treatment or monitoring, it is expected that physician availability and involvement would be consistent with current best practices of care. 
  3. In the event the patient may have a comorbid psychiatric condition that interferes with abstinence, recovery, or stability but is not so severe as to warrant acute inpatient psychiatric hospitalization, then a psychiatrist must be involved in the treatment. 
  4. The patient must meet the following criteria: The patient is coherent, rational, and cognitively able to absorb treatment. The mental state of the patient does not preclude the patient's ability to:
    1. comprehend and understand the materials presented 
    2. actively participate in rehabilitation/treatment process.

Absence in the past year of a withdrawal history of delirium tremens, seizures, hallucinations, or acute psychotic reaction secondary to chronic alcohol and/or substance use.

Intensity of Service (IS)

Section A. Must satisfy ALL of the following criteria:

  1. Documentation of blood, breath and/or urine drug screen results upon admission.
  2. Multi-disciplinary problem-focused treatment plan that addresses psychological, social (including living situation and support system), medical, substance use, and rehabilitation needs. 
  3. Examination by a physician (preferably a psychiatrist or addictionologist) within 24 hours of admission and availability of a physician for consultation on a daily basis while in detoxification phase. 
  4. Eight (8) hour skilled nursing (either RN or LVN) on site with 24-hour availability. [Note: If the patient's medical symptoms require 24-hour nursing care for assessment, frequent administration of medication, monitoring of vital signs and other services only provided by a nurse, then acute inpatient detoxification is required.] 
  5. Medication management of withdrawal symptoms. 
  6. Family program and involvement, including individual family sessions 1-2 times per week, as appropriate, unless clinically contraindicated. 
  7. Discharge planning is initiated on the day of admission and includes appropriate continuing care plans.
  8. All psychotherapeutic services are provided by licensed or certified professionals in accordance with state requirements.

Continued Stay Criteria

Must continue to meet "SI/IS" Criteria and have ALL the following to qualify:

  1. Focus of the initial treatment plan is being continuously updated to account for clinical changes and identify medical, substance use or psychiatric co-morbidity. Treatment plan remains focused on objectively measurable goals and is time limited. Progress on Treatment Goals is being documented (see "IS"). 
  2. The program is actively pursuing a plan to ensure that the patient participates in a continuing recovery program after discharge. The plan should provide for continued treatment to occur at the least restrictive level of care possible. The treatment team is making diligent efforts to encourage the patient and his family/significant others to initiate treatment in a community support group and to clear the patient's home of all substances of abuse. 
  3. Family/ support system is actively involved, as indicated, and responsive to treatment recommendations.
  4. Documentation indicates continuing significant, yet subacute, withdrawal symptoms and need for continued withdrawal treatment and support.

Comment:

Worsening of the clinical symptoms should trigger a review by Medical Director.

Discharge Criteria

Must have one (1) of the following to qualify:

  1. Patient's medical and psychological stability meet criteria for lower level of care.
  2. Medical detoxification is completed and patient meets criteria for transition to CD Rehab/RTC/PHP/IOP. 
  3. The probability of successful outcome with continued treatment at this level is seriously compromised because the patient is non-compliant with treatment and/or has no desire to attend self-help abstinence based groups. Examples of non-compliance include, but are not limited to: active substance use disorder, refusal of clinically indicated medications or psychiatric consultation, poor attendance at program activities, failure to engage in the treatment process and refusal to attend community support groups recommended by the program. Family or significant others (when available) fail to participate in the patient's treatment. There is little evidence that intervention thus far has improved compliance.
  4. The clinical information does not offer evidence that the current treatment plan is effective. There is no alternate appropriate treatment plan proposed and further progress toward specific measurable treatment goals is deemed unlikely at this level.

1 ASAM Placement Criteria, Second Edition Revised; ASAM 2001.

2. Adult Residential Subacute Detox Criteria

Effective Date: 10/09/2007
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Definition:

Subacute Detoxification is an appropriately licensed organized freestanding service that may be delivered by appropriately trained staff, which provides 24-hour supervision, observation and support for patients who are experiencing withdrawal or evidence of impending withdrawal. However, the full resources of a medically monitored inpatient detoxification service are not necessary.1 Other forms of Subacute Detoxification include Ambulatory Detox as in ASAM 1D and 2D, and are covered under the InterQual Level of Care guidelines. Subacute residential detoxification is generally characterized by its emphasis on peer and social support. This is a Social Model Program (corresponding to ASAM level III.1 only). Placement in a Social Model Program should occur only after evaluation has been done by a physician (preferably by a Psychiatrist or Addictionologist) to assess for medical stability and for the presence of Co-Morbid Mental Illness. This level of care is provided only to patients who have a DSM diagnosis of Substance Use Disorder and their substance abuse has caused a significant impairment in their level of social and/or occupational functioning. Patients who are in late stages of detoxification and are not at risk for further physiological deterioration are considered sufficiently medically stable for treatment at this level of care.

Comments:

A residential Subacute Detoxification Program must meet the following criteria:

  • Program needs to have established clinical protocols to identify patients who are in need of medical services beyond the capacity of the facility and to transfer such patients to more appropriate levels of care. 
  • Program needs to be able to arrange for appropriate laboratory and toxicology tests 
  • Program is staffed by appropriately credentialed personnel who is trained and competent to implement physician-approved protocols for patient observation and supervision 
  • Program is designed explicitly to safely detoxify patients without the need for ready on-site access to medical personal 
  • Medical evaluation and consultation is available 24 hours a day 
  • All clinicians who assess and treat patients are able to obtain and interpret information regarding the needs of the patients. This includes knowledge of: 
    • Signs and symptoms of alcohol and other drug intoxication and withdrawal states 
    • Appropriate treatment and monitoring of these intoxication or withdrawal states 
  • Facilities that supervise self-administered medications have appropriately licensed or credentialed staff and policies and procedures accordance with state and federal law 
  • Staff assure that the patients are taking medications according to physician prescription and legal requirements 
  • Program provides daily clinical services to assess and address needs of each patient including medical services, individual and group therapies, and withdrawal support 

The following guidelines are suggested for an individualized Substance Use Disorder Subacute Detoxification treatment plan as clinically indicated:

  • Individual counseling daily. 
  • Group counseling daily. 
  • Family psychotherapy 1- 2X/week. 
  • Milieu therapy daily. 
  • Substance Use Disorder - 12-step group daily. 
  • Medication management (when indicated) at least 1X/wk.

If clinical presentation suggests that intensive family intervention is critical, then patient should be referred to the closest geographical facility to their home. This would facilitate and smooth transition to lower levels of care and aftercare.

Admission Criteria:

Severity of Illness (SI)

Section A. Must satisfy ALL of the following criteria:

  • The nature and pattern of use of abused substances (including frequency and duration) predicts withdrawal potential, however, the patient is at minimal risk of medically-complicated withdrawal and there is little chance that withdrawal from psychoactive substances could potentially be life threatening. 
  • There is minimal risk that the patient's medical condition(s) or the presence of medical complications places the patient in imminent danger of serious health risk and they can be managed at a Subacute Detoxification Level of Care. If there is a medical condition requiring treatment or monitoring, it is expected that physician availability and involvement would be consistent with current best practices of care. In the event the patient may have a comorbid psychiatric condition that interferes with abstinence, recovery, or stability but is not so severe as to warrant acute inpatient psychiatric hospitalization, then a psychiatrist must be involved in the treatment. 
  • The patient must meet the following criteria: 
    • The patient is coherent, rational, and cognitively able to absorb treatment. 
    • The mental state of the patient does not preclude the patient's ability to: 
      • comprehend and understand the materials presented 
      • actively participate in rehabilitation/treatment process. 

Absence in the past year of a withdrawal history of delirium tremens, seizures, hallucinations, or acute psychotic reaction secondary to chronic alcohol and/or substance use.

Intensity of Service (IS)

Section A. Must satisfy ALL of the following criteria:

  • Documentation of blood, breath and/or urine drug screen results upon admission. 
  • Multi-disciplinary problem-focused treatment plan that addresses psychological, social (including living situation and support system), medical, substance abuse, and rehabilitation needs. 
  • Examination by a physician (preferably a psychiatrist or addictionologist) within 24 hours of admission and availability of a physician for consultation on a daily basis while in detoxification phase. 
  • Eight (8) hour skilled nursing (either RN or LVN) on site with 24-hour availability. [Note: If the patient's medical symptoms require 24-hour nursing care for assessment, frequent administration of medication, monitoring of vital signs and other services only provided by a nurse, then acute inpatient detoxification is required.] 
  • Medication management of withdrawal symptoms. 
  • Family program and involvement, including individual family sessions 1-2 times per week, as appropriate, unless clinically contraindicated. 
  • Discharge planning is initiated on the day of admission and includes appropriate continuing care plans.

All psychotherapeutic services are provided by licensed or certified professionals in accordance with state requirements.

Continued Stay Criteria

Must continue to meet "SI/IS" Criteria and have ALL the following to qualify:

  • Focus of the initial treatment plan is being continuously updated to account for clinical changes and identify medical, substance abuse or psychiatric co-morbidity. Treatment plan remains focused on objectively measurable goals and is time limited. Progress on Treatment Goals is being documented (see "IS"). 
  • The program is actively pursuing a plan to ensure that the patient participates in a continuing recovery program after discharge. The plan should provide for continued treatment to occur at the least restrictive level of care possible. The treatment team is making diligent efforts to encourage the patient and his family/significant others to initiate treatment in a community support group and to clear the patient's home of all substances of abuse. 
  • Family/ support system is actively involved, as indicated, and responsive to treatment recommendations.

Documentation indicates continuing significant, yet subacute, withdrawal symptoms and need for continued withdrawal treatment and support.

Comment:

Worsening of the clinical symptoms should trigger a review by Medical Director.

Discharge Criteria

Must have one (1) of the following to qualify:

  • Patient's medical and psychological stability meet criteria for lower level of care. 
  • Medical detoxification is completed and patient meets criteria for transition to CD Rehab/RTC/PHP/IOP. 
  • The probability of successful outcome with continued treatment at this level is seriously compromised because the patient is non-compliant with treatment and/or has no desire to attend self-help abstinence based groups. Examples of non-compliance include, but are not limited to: active substance abuse, refusal of clinically indicated medications or psychiatric consultation, poor attendance at program activities, failure to engage in the treatment process and refusal to attend community support groups recommended by the program. Family or significant others (when available) fail to participate in the patient's treatment. There is little evidence that intervention thus far has improved compliance.

The clinical information does not offer evidence that the current treatment plan is effective. There is no alternate appropriate treatment plan proposed and further progress toward specific measurable treatment goals is deemed unlikely at this level.

1 ASAM Placement Criteria, Second Edition Revised; ASAM 2001.

3. Adult Substance Use Disorder Relapse Prevention Outpatient Aftercare Group

Effective Date: 11/14/2001
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Definition:

Relapse Prevention Group is an aftercare group treatment and is typically used as step-down from Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP). Minimum group leadership requirement includes a certified substance abuse counselor supervised by mental health/substance abuse professional. The sessions are weekly and last up to 90 minutes. The duration of the program varies according to medical necessity.

Comments:

Relapse Prevention Aftercare Substance Use Disorder (SUD) Group is frequently used as a typical step-down treatment modality after SUD IOP. It has the advantages of longer duration of program contact and support for the patient while functioning in their actual true life environment.

A single drug binge episode may be adequately addressed in this treatment setting and would not necessarily be in itself a reasonable cause for stepping up treatment to a higher level of care.

Relapse Prevention Aftercare Group will not replace the need for patient's involvement in local self-help groups, alumni groups and activities. It can also co-exist with other treatment modalities as medically necessary (medication management, individual counseling, family, couple or marital counseling).

Admission Criteria - Requires ALL:

  1. There is a DSM diagnosis of Substance Use Disorder and there is a documented history of recent substance abuse or dependence that was severe enough to markedly interfere with social and occupational functioning and cause significant impairment in activities of daily living.
  2. Patient requires continued participation in the relapse prevention group in order to maintain abstinence and seek additional support in defending against urges and cravings and to build adequate coping skills to handle triggers and stress. 
  3. Patient's recovery environment, living situation, and social support system are sufficiently stable to allow for meaningful participation in the Relapse Prevention Aftercare Group. There is a strong expectation that patient will attend self-help or abstinence community support groups. 
  4. There is evidence of sufficient motivation for successful participation in treatment at this level of care; and 
  5. Patient has demonstrated, or there is reason to believe that the patient can avoid the abuse of substances between treatment sessions.

Continuing Stay Criteria - Requires ALL:

  1. Patient must have a DSM diagnosis of substance use disorder. 
  2. Patient continues to be at risk for relapse due to active stress, frequent urges or cravings and/or patient has significant co-existing psychiatric symptoms. 
  3. Patient requires continued participation in the group in order to maintain abstinence and seek additional support in defending against urges and cravings of substance use and to build adequate coping mechanisms to handle triggers and stress. 
  4. Patient needs to further develop a support system, including use of self-help, sponsor and access to community resources. There is evidence that patient has attempted to engage the participation of family members or significant others as part of their sober support system. 
  5. The patient is able to maintain abstinence between group sessions. 
  6. Patient is clearly demonstrating progress in treatment at this level of care.

Comment:

A single relapse, worsening of the clinical symptoms or multiple unscheduled absences (3 or more) should trigger a review by Medical Director.

Discharge Criteria - Requires ONE:

  • Patient is able to maintain abstinence with help from available support system. Patient is actively participating (where appropriate) in community sponsored self-help groups, attends them regularly and has a sponsor. Family/significant others if available can provide adequate support. 
  • The probability of successful outcome with continued treatment at this level is seriously compromised because patient and/or family or significant others are non-compliant with treatment recommendations. Examples may include but are not limited to: active substance use, refusing medications or psychiatric consultation when clinically indicated, poor attendance, failure to readily engage in the treatment process and/or refusal to attend treatment offered by community support groups when it is thought to be a critical element in successful treatment. 
  • There is little evidence that intervention thus far has improved compliance. There is little evidence that the current treatment plan is effective. There is no alternate appropriate treatment plan proposed. Further progress is deemed unlikely at this level.

4. Child and Adolescent Substance Use Disorder Relapse Prevention Outpatient Aftercare Group

Effective Date: 1/09/2002
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Definition:

Relapse Prevention Group is an aftercare group treatment, is typically used as step-down from IOP or PHP. Minimum group leadership requirement includes a certified substance use disorder counselor supervised by mental health/substance use professional. The sessions are weekly and last up to 90 minutes. The duration of the program varies according to medical necessity.

Comments:

Relapse Prevention Aftercare Substance Use Disorder (SUD) Group helps extend the supportive therapeutic duration of program contact for the patient while functioning in their actual true life environment. .

A single drug binge episode may be adequately addressed in this treatment setting and would not necessarily be in itself a reasonable cause for stepping up treatment to a higher level of care.

Relapse Prevention Aftercare Group will not replace the need for patient's involvement in local self-help groups, alumni groups and activities. It can also co-exist with other treatment modalities as medically necessary (medication management, individual counseling,or family counseling).

Admission Criteria - Requires ALL:

  1. There is an DSM 5 diagnosis of Substance Use Disorder and there is a documented history of recent substance use that was severe enough to markedly interfere with social and occupational functioning and cause significant impairment in activities of daily living. 
  2. Patient requires continued and consistent participation in the relapse prevention group in order to maintain abstinence and seek additional support in defending against urges and cravings and to build adequate coping skills to handle triggers and stress. 
  3. Patient's recovery environment, living situation, and social support system are sufficiently stable to allow for meaningful participation in the Relapse Prevention Aftercare Group. 
  4. Parent(s)/legal guardian(s) are sufficiently motivated to support patient's abstinence. There is a strong expectation that patient will attend self-help or abstinence community support groups. 
  5. There is evidence of sufficient motivation for successful participation in treatment at this level of care; and, 
  6. Patient has demonstrated, or there is reason to believe that the patient can avoid using substances between treatment sessions. 

Continuing Stay Criteria - Requires ALL:

  1. Patient must have a DSM 5 SUD diagnosis. 
  2. Patient continues to be at risk for relapse due to active stress, frequent urges or cravings and/or patient has significant co-existing psychiatric symptoms. 
  3. Patient requires continued participation in the group in order to maintain abstinence and seek additional support in defending against urges and cravings of substance use and to build adequate coping mechanisms to handle triggers and stress. 
  4. Patient needs to further develop a support system, including use of self-help, sponsor and access to community resources when appropriate. There is evidence that patient has the support and participation of parent(s)/legal guardian(s) as part of their sober support system. 
  5. The patient is able to maintain abstinence between group sessions. Patient is clearly demonstrating progress in treatment at this level of care.

Comment:

A single relapse, worsening of the clinical symptoms or multiple unscheduled absences (3 or more) should trigger a review by Medical Director. Discharge Criteria: Requires ONE:

  • Patient is able to maintain abstinence with help from the support system available. Patient is actively participating (where appropriate) in community sponsored self-help groups, attends them regularly and has a sponsor. Parent(s)/legal guardian(s) provide adequate support. 
  • The probability of successful outcome with continued treatment at this level is seriously compromised because the patient and/or parent(s)/legal guardian(s) are non-compliant with treatment recommendations. Examples may include but are not limited to: active substance use, refusing medications or psychiatric consultation when clinically indicated, poor attendance, failure to readily engage in the treatment process and/or refusal to attend treatment offered by community support groups recommended by the program, patient and/or parent(s)/legal guardian(s) fail to participate in patient's treatment. There is little evidence that intervention thus far has improved compliance. 
  • There is little evidence that the current treatment plan is effective. There is no alternate appropriate treatment plan proposed. Further progress is deemed unlikely at this level.

9.2 Position Statements

Effective Date: 05/20/2011
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Rationale: To provide criteria to guide providers" requests and health plan review for authorization of psychological and neuropsychological testing

Purpose: Psychological and Neuropsychological Testing should be viewed as a specialty procedure available to providers, to assist in the assessment and treatment of more difficult, challenging, recalcitrant, and/or complex cases. Each request for benefit coverage is evaluated on its merit. All authorizations for testing service are contingent on member eligibility, benefit inclusion and exclusion criteria specified in the member's Evidence of Coverage or other summary plan document, and applicable State/Federal laws and regulations. MHN utilizes McKesson's InterQual Behavioral Health Criteria as a guide for authorizing psychological and neuropsychological testing. InterQual Behavioral Health Criteria are objective, evidence-based criteria that support evaluation and care decisions. InterQual criteria are reviewed and revised annually by McKesson's clinical team.

 

Uses of Psychological Testing:

1. Screening: Not supported by MHN as a primary reason for requesting formal psychological testing.
Objective tests used in routine psychotherapy practice by all clinical (and medical) license types (Master's, Doctorate, MD/ARNP/PCP).
BDI, BAI, BSI, PHQ-9. SCL-90, ZUNG, Hamilton, ADHD screening tools.

2. Diagnosis

Key to development of a treatment plan is accurate diagnosis of problems for which patient is seeking intervention/treatment. Usually, authorization of a full psych testing battery is not needed. Clinicians will use Structured Clinical Interview for DSM 5 (SCID), not considered formal psychological testing. MHN firmly holds that the community standard requires an initial comprehensive clinical interview (CPT 90791), and it is only if through the gathering of history and mental status examination that a diagnosis cannot be clarified, that psychological testing may be appropriate.

Differential Diagnosis " Primary purpose of psychological testing requests. However, no authorization is given unless these are provider generated requests. For member requests, authorize CPT 90791 to psychologist testing provider, unless purpose of testing is an exclusion.

3. Treatment Planning

At times, assessment of patient's personality resources and liabilities can save time and money, and avoid misplaced therapeutic efforts, enhance likelihood of favorable treatment outcomes. Used for treatment matching, as well as to monitor treatment progress and to detect treatment obstacles.

Used when patient has limited response to medications, or in treatment for many sessions with little progress; similar to referring for second opinion.

4. Treatment Monitoring and Outcomes

Similar to treatment planning; used to determine how treatment is progressing and to know when termination is warranted.

Re-testing to determine treatment progress or lack thereof, or for neuropsychological testing to gauge progress of recovery or lack of, monitor changes in functioning, e.g., neurological injury, use of brief screening tests to monitor symptom progression of identified symptoms.

Procedures and Requirements for Authorization

All of the following criteria are met:

  1. Testing benefits must be available under the member's Evidence of Coverage or relevant summary plan document.
  2. The request for testing is completed after the member has been seen for an initial evaluation by a qualified psychologist (see #6 below) and has sufficient clinical information to develop an appropriate testing battery and communicate that in the form of a testing request.
  3. When requesting neuropsychological testing to address relevant medical/behavioral issues, the request should be preceded by a mental status examination, and review of the member's pertinent history and an appropriate medical and/or neurological consultation report that recommends neuropsychological testing.
  4. Testing is authorized to address a specific diagnostic question that could not otherwise be answered by a standard clinical interview evaluation.
  5. The request is for an individualized testing battery based on the patient's unique clinical presentation. Medical Necessity is not satisfied if the request is based upon a standard operating procedure or if the testing request is not tailored to the individual in need.
  6. The testing process is conducted or supervised by an independently licensed psychologist with training and expertise in the types of tests/assessment being requested and can perform them at a level proficient to interpret testing data in accordance with the American Psychological Association standards of practice (Ethical Principles of Psychologists and Code of Conduct).
  7. The tests and number of hours requested are consistent with the reason for testing, and are not in excess of that necessary in order to obtain a valid assessment outcome, The reimbursable time for test administration is based on published standards or time(s) reported by the test/publisher, and supplemented as needed by published test usage surveys of psychologists engaged in testing activities (e.g.," Psychological Test Usage: Implications in Professional Psychology," by W. J. Camara, J. S. Nathan, and A. E. Puente, 2000, Professional Psychology: Research and Practice, 31, 141-154). In the absence of such information for a particular request, reimbursable administration time is based on what MHN has deemed appropriate according to commonly accepted test administration times.

Psychological Testing

Psychological testing is a set of formal procedures that make use of reliable and valid tests and measures to assess intellectual/cognitive ability, psychopathology, personality style and organization, emotional and/or interpersonal processes, behavioral functioning, and adaptive skills. Types of psychological testing include self-reported questionnaires, rating scales (e.g., the Beck Depression Inventory, Hamilton Depression Rating Scale), objective tests (e.g., the MMPI-2. MCMI, MACI), and brief screening tests of cognitive function (e.g., the Folstein MMSE or the MOCA).

For psychological testing to be authorized, there is an expectation that testing services are requested for situations where review of relevant history, diagnostic clinical interview, mental status examination, administration of brief/ad hoc screening measures and self-report inventories/assessments, and consultation with collateral sources will be insufficient to address the referral question(s)/issues.

Any one of the following criteria must be met:

  1. Testing contributes necessary clinical information for differential diagnostic clarification.
  2. Results of testing are required to formulate a treatment plan or are required to make necessary revisions to an existing treatment plan.
  3. The treatment response is significantly different from the expected response based on the treatment plan.
  4. It is necessary to evaluate a member's functional capacity to participate in behavioral health treatment.

Criteria for Denial of Authorization for Psychological Testing:

  • The answer to the testing question(s) can be obtained from other sources of data (neurologist, more thorough psychosocial assessment, brief screeners, psychiatric evaluation, school system, pediatrician).
  • The testing results will be used only to confirm a diagnosis that is clinically suggested by initial evaluation.
  • The testing will be used to determine the presence of a diagnosis or appropriateness of a treatment that is not covered in the patient's benefit plan (e.g.,testing for V-codes; testing for legal purposes; vocational testing; pre-surgical evaluation for HealthNet-California plans--see #12 below).
  • Psychological testing directly related to the measurement of associated academic/educational problems, academic achievement level, ADHD testing alone, learning disabilities, intelligence (IQ) testing alone, and intellectual disability may be excluded from coverage, depending on coverage exclusions listed in the member's Evidence of Coverage or relevant summary plan document.
  • A qualified provider has not first assessed the patient at the time of the request, using CPT 90791.
  • Psychological testing as a boilerplate, i.e., routine part of a psychologist's assessment of ALL patients.
  • Request is for a reason other than to assist in the formulation of a diagnosis or treatment plan for a psychological disorder (achievement testing for school placement; intellectual or vocational interest assessment), or for purposes of specifying aspects of the patient's problems beyond the point of actually impacting the treatment plan, such as member requests for IQ or ADHD testing.
  • Patient's stress and/or associated psychological impairment are related to obvious current stressors, and insufficient time has passed to allow for the effectiveness of treatment interventions to be assessed.
  • The tests requested do not have empirical support or validity to address to address the question(s).
  • The psychological testing can be appropriately performed by another organization, such as public school system, and regional centers in some cases.
  • Psychological testing is court-ordered, but unrelated to the determination of a diagnosis or development of a treatment plan, such as determination of competency to stand trial, child custody, etc.
  • Psychological testing as a component of pre-surgical evaluation is most often conducted when needing to rule out psychiatric conditions potentially contra-indicative of surgery, to determine a member's ability to understand the risks of surgery, and/or to evaluate the member's ability to participate responsibly in post-surgical recovery behaviors and lifestyle changes. Unless specifically listed as a covered behavioral health benefit in the member's Evidence of Coverage, these requests are referred to the member's medical plan.
  • Psychological testing administered when the patient has a history of substance use disorder and any of the following apply:
    • The patient has ongoing substance use such that test results would be inaccurate; or
    • The patient is currently intoxicated; or
    • The patient is not yet 10 or more days post-detox; or
    • The patient is on certain daily medications that may confound interpretation of results, and drug effects have not been ruled out.

Procedure for Review of Psychological Testing Requests:

MHN care managers will review provider/member requests received according to MHN Psychological and Neuropsychological Testing Policy and Procedure, MHN Position Statement on Criteria & Guidelines for Authorization of Psychological and Neuropsychological Testing and Timeliness Standards for Utilization Management Decision Making and Notification Policy and Procedure. Once a provider completes CPT 90791 and a formal psychological testing request form is received, the care manager will review the request, including specific tests and number of hours being requested. If the request meets criteria as documented herein, the care manager will authorize the average industry standard of up to 6 hours. If the provider request does not meet criteria or is in excess of 6 hours, the care manager will discuss the request with their clinical supervisor and/or refer the request for medical director/peer review. Additionally, if the care manager has a question as to whether the request is for psychological testing or neuropsychological testing, they will discuss the request with the requesting provider, their clinical supervisor and/or refer the request for medical director/peer review.

Special Considerations:

There are some testing requests that originate with a Health Net PCP or MHN provider specifically referring the member to be tested. This occasionally occurs with referrals for ADHD, Autism Spectrum Disorders, and cognitive impairment related symptomology, among others. The care manager should review all these types of requests, that otherwise may not meet medical necessity criteria, with their supervisor, since the member is following the direction of a Health Net or MHN provider. An override of criteria may be necessary in certain limited situations for customer service consideration as well as regulatory compliance.

Neuropsychological Testing

Neuropsychological testing is specifically focused on providing information relevant to the determination of the presence of damage or dysfunction of the brain and associated functional deficits. Requests for neuropsychological testing may require considerations beyond those for intellectual, basic cognitive, and personality testing. Neuropsychological testing consists of the administration of a series of standardized assessments designed to objectively measure higher cognitive function. This testing provides the basis for the conclusions regarding the neuro-cognitive effects of various medical disorders and aids in diagnosis. Neuropsychological testing is also used to assist in the differentiation of psychiatric from neurological disorders. Making an assessment of preserved and compromised cognitive functions can also help to predict the effects of remediation. Neuropsychological testing is indicated when notable behavioral and/or cognitive changes have been associated with a history of severe head trauma or organic brain disease. The testing results assist the clinician to determine the scope and severity of cognitive impairments through a comparison of patient responses to established normative test values. This comparison then assists the clinician in developing a program or plan of care that is specific to the patient's needs. Neuropsychological testing should be delayed until reversible medical or metabolic conditions that are adversely affecting the central nervous system (CNS) are corrected, when possible. Formal neuropsychological testing should also be delayed until any acute changes have stabilized following trauma, infections, or metabolic or vascular insults to the CNS, e.g., acute stroke, traumatic brain injury (TBI).

The components of neuropsychological assessment include all of the following:

  • Assessment of higher cortical functions, which includes thought process and organization, reasoning and judgment.
  • Assessment of attention, language, memory and problem-solving.
  • Obtaining a developmental history, the history of medical disease, trauma and psychiatric illness, and the history of the person's cognitive decline and/or premorbid level of function.

Neuropsychological testing differs from psychological testing in that neuropsychological testing measures higher cerebral functioning, which focuses on cognitive skills and abilities (i.e., language, memory and problem-solving), whereas psychological testing is designed to provide information about a patient's personality and emotional functioning.

Neuropsychological testing, when medically referred and for the evaluation of known or suspected brain impairment due to injury or disease

process, may be covered through the member's medical benefits. Below is the current MHN criteria excerpted from Mixed Services Policy and Procedure:

Service Type
Applicable Benefit
Financial Responsibility

Care Management Responsibility

5. Neuropsychological testing

* Referral source is a behavioral health specialist AND there is a current version of the DSM primary working diagnosis that is not excluded under the terms of the contract, and services are authorized by MHN

* Referral source is not a behavioral health specialist OR the working diagnosis is not an included current version of the DSM primary diagnosis

MHSA

MED

MHN

HP

MHN

MHNF

MED = Medical Benefit

MHSA = Mental Health/Substance Abuse Benefit

HP = Medical Carrier/Health Plan

MHN = Managed Health Network.

MHNF = MHN facilitates, but does not assume financial responsibility; MHN serves as a consultant regarding medical necessity and may identify a provider for the health plan. However, the health plan is responsible for authorizing and paying for services.

As with general psychological testing, neuropsychological testing is considered when other sources of information are insufficient to answer the referral question

and testing is necessary to answer the specific referral question(s).

Neuropsychological testing is appropriate for one or more of the following purposes:

  • To screen for the presence of suspected neuropsychological impairment.
  • The results of testing are necessary to provide differential diagnosis of a psychiatric disorder versus a neurological or medical condition with cognitive and/or psychiatric symptoms.
  • The results of testing are necessary to rule in or out diagnostic conditions when known or suspected neurological disease is not detected or is not certain through the use of standard psychiatric and/or medical/neuro-diagnostic examination and procedures.
  • The assessment of clinical conditions where there is the likelihood of specific brain-based pathology, including: head injuries, moderate-severe dementia, encephalopathy (when there is a specific medical condition (e.g., HIV) causing loss of functioning), brain tumor with associated/suspected cognitive impairment, multiple sclerosis with associated/suspected cognitive impairment, epilepsy with seizure history and associated/suspected cognitive impairment, exposure to neurotoxins; and some cases of developmental delay or disorder (e.g., Cerebral Palsy with associated/suspected cognitive impairment, hydrocephalus with associated/suspected cognitive impairment, structural malformation of the brain or chromosomal/genetic defect that affects brain function with associated/suspected cognitive impairment, language disorder with associated/suspected cognitive impairment, certain cases of prematurity with associated/suspected cognitive impairment); andthese conditions raise significant neuro-behavioral diagnostic questions and/or treatment issues.
  • The results of testing are required to determine the member's baseline neuro-cognitive functioning when future change is reasonably anticipated and/or to determine changes in functioning from a previous baseline, andare necessary to assist with treatment planning.
  • The results of testing are necessary to determine the member's cognitive rehabilitation needs and/or discharge planning or placement needs, when other planning or therapy has been unable to determine appropriate discharge placement.
  • Psychological testing to assess pain conditions is most often conducted when there is a need to assess mood and personality characteristics co-existing with a pain condition and when believed potentially to be influencing pain, when the member shows evidence of cognitive or intellectual disturbances after discontinuation or non-response to pain-relieving and psychotropic medications, and/or to assess co-existing substance abuse issues.

Criteria for Denial of Authorization for Neuropsychological Testing:

  • Differentiating between two or more possible psychiatric diagnoses.
  • Diagnosing non-neurologically complicated cases of ADHD.
  • Assessing a non-neurologically complicated learning disability and developing an educational or vocational plan. Developmental testing (CPT 96110, 96111) most often is conducted by a developmental pediatrician, or a speech, language, physical or occupational therapist as part of a multi-disciplinary evaluation of a developmental condition, and so usually requires coverage approval and reimbursement through the member's medical benefit, based on the member's Evidence of Coverage or other summary plan document. An exception to this is when these CPT codes are included in an battery of tests being approved for autism spectrum disorders in children and adolescents.
  • The patient is not neurologically and cognitively able to participate in a meaningful way with the requirements necessary to successfully perform these tests.
  • When used as screening tests given to the individual or to general populations.
  • School based testing.
  • In the assessment of patients with acute stroke, prior to a period of rehabilitation.
  • Performed when abnormalities of brain function are not suspected.
  • Used for self-administered or self-scored inventories, or screening tests of cognitive function (e.g., Folstein Mini-Mental Status Examination).
  • Repeated when not required for medical decision-making (i.e., making a diagnosis or deciding whether to continue a particular rehabilitative or pharmacologic therapy).
  • Administered when the patient has a history of substance use disorder and any of the following apply:
    • The patient has ongoing substance use such that test results would be inaccurate; or
    • The patient is currently intoxicated; or
    • The patient is not yet 10 or more days post-detox; or
    • The patient is on certain daily medications that may confound interpretation of results, and drug effects have not been ruled out;
  • Neuropsychological assessments can be obtained through the clinical evaluation alone (e.g., response to medication).
  • The patient has been diagnosed previously with brain dysfunction, and there is no expectation that the testing would further impact the patient's management.
  • Periodic testing performed when the patient is stable.
  • The patient has an adjustment disorder or dysphoria associated with a medical condition and/or moving to a skilled nursing facility or nursing home.
  • When standardized batteries of tests, not individualized to the patient's complaint or referral question, are administered when only a subset of tests is required.
  • Personality tests, such as MMPI, and/or projective tests such as Rorschach, Thematic Apperception Test, without a neuro-cognitive injury/impairment present.

Procedure for Review of Neuropsychological Testing Requests:

MHN care managers will review provider/member requests received according to HN Medical Policy on Neuropsychological Testing, MHN Psychological and Neuropsychological Testing Policy and Procedure, MHN Position Statement on Criteria & Guidelines for Authorization of Psychological and Neuropsychological Testing and Timeliness Standards for Utilization Management Decision Making and Notification Policy and Procedure. Once a provider completes CPT 90791 and a formal neuropsychological testing request form is received, the care manager will review the request, including specific tests and number of hours being requested. MHN utilizes McKesson's InterQual Behavioral Health Criteria as a guide for authorizing neuropsychological testing. If the request meets InterQual criteria and/or criteria as documented herein, the care manager will authorize up to the maximum allowable hours specified by InterQual. If the provider request does not meet InterQual criteria or is in excess of the maximum allowable hours, the care manager will discuss the request with their clinical supervisor and/or refer the request for medical director/peer review. Peer reviewers utilize McKesson's InterQual Behavioral Health Criteria as a guide for authorizing neuropsychological testing, including maximum number of hours.

Additionally, industry standard does not support the practice of a provider requesting both psychological and neuropsychological testing in one request for a member. It is considered standard practice that some neuropsychological testing requests will include psychological tests and should be reviewed under the same guidelines contained within, utilizing McKesson InterQual Criteria, and should not be separated into two requests. If the care manager has a question as to whether the request is for psychological testing or neuropsychological testing, they will discuss the request with the requesting provider, their clinical supervisor and/or refer the request for medical director/peer review.

 

Effective Date: 11/7/2011
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

It is MHN's practice to refer members to providers that meet the criteria required for the provision of high quality behavioral health services. When this kind of referral cannot be made to an MHN contracting provider, we may need to make or approve a referral outside the existing MHN Network.

There are situations in which the member's request for care with a non-contracting provider is related to that provider's clinical specialty or expertise. That is when the member contends that MHN's network providers do not have comparable experience in the well-established clinical specialty for which treatment is being sought. In these instances, members often request that a Single Case Agreement (SCA) be negotiated. The goal of this document is to specify the conditions under which this determination requires a medical necessity question to be answered or defined. This process requires a Medical Director review and will result in a clinical decision.

MHN has researched the regulatory requirements and believes that in such instances a medical necessity review and clinical decision is appropriate. If denied, the member will have all levels of appeal available. The decision must be a clinical one with the Medical Director as the decision maker. An MHN Medical Director will determine whether a specific treatment is medically necessary and can only be provided by the unique non-contracting provider being requested, and whether that provider's expertise/credentials/experience cannot be duplicated by a contracted provider in MHN's network within the member's geographic region.

Note: If the SCA question is not a clinical one, such as a member who wants an SCA with a non-contracting provider because he likes that provider or because it is more convenient, an administrative denial would be issued for that SCA request. If the member has out of network benefits, he or she would be directed to access that benefit. The administrative denial is issued after MHN has carefully researched and located at least one appropriate contracted MHN provider who practices in the member's geographic area, and has available hours within a reasonable time frame and has the clinical specialty/credentials/experience required to adequately treat the member's condition.

Effective Date: 08/01/2007
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Dialectical* Behavior Therapy

* Debate intended to logically resolve a conflict between two contradictory or apparently contradictory ideas or parts, establishing truths on both sides rather than disproving one argument (Encarta 2007).

Dialectical Behavior Therapy (DBT, Linehan, 1993) is a systematic cognitive-behavioral, support-oriented and collaborative approach proven to work effectively with borderline personality disorder (BPD) patients, especially those with chronic patterns of suicidal or other dangerous behaviors. DBT is a melding of acceptance, validation and behavior therapy change strategies, guided by rational investigation of triggers, resultant behaviors and their natural consequences. Texts describing the fundamental treatment methodology and theory include: Cognitive-Behavioral Treatment for Borderline Personality Disorder (1993), New York: Guilford Press, and Skills Training Manual for Treating Borderline Personality Disorder (1993), New York: Guilford Press, both by Marsha Linehan. Also, a text describing DBT with adolescents is by Miller AL, Rathus JH, Linehan MM and Swenson, CR, Dialectical Behavior Therapy with Suicidal Adolescents (2006), New York: Guilford Press.

Patient Populations

In treating chronically parasuicidal patients with BPD and adolescents, DBT was more effective than community based treatment-as-usual in reducing incidence and severity of parasuicidal acts (including suicide attempts), therapy drop-outs, inpatient psychiatric days, and self-reported anger, and in increasing interpersonal and global adjustment (Linehan, 1991, 1993, 1994, 2006, Miller et al 2006). Intensive (three weeks, daily treatment) DBT for Outpatients with BPD who were in crisis resulted in high treatment completion, and a significant drop in depression and hopelessness measures (McQuillan et al, 2005). Research indicates that DBT might have some effect in stabilization of spectrum mood disorders, including self-injury, dissociative disorders and traumatic brain injury (TBI). DBT was adapted for use in BPD opiate-users (DBT-S) with promising initial pilot data. The major modifications to standard DBT are the addition of 1) specific targets relevant to drug use, 2) a set of attachment strategies, 3) a drug replacement program 4) weekly urinalysis, and 5) case management. Several studies have demonstrated the efficacy of DBT in stabilization of eating disorders (Bulimia and Binge Eating Disorder).

Program Structure and Training

DBT is effective when used by professionals specifically trained in its technical procedures. The recommended training in the treatment includes all three elements of the standard DBT structure: 1) one-on-one individual therapy, 2) group skills training, and 3) therapist consultant teams. According to Linehan, there is not enough evidence supporting the efficaciousness of treatment with only one or two of these components alone. A study that compares those that get the full package to those that only get group skills training and those that only get DBT individual training is under way. The standard DBT treatment program typically meets 3-5 times a week, and works most effectively if applied over a period of 3 months to a year. A full DBT Program typically covers four modules including training and practice sessions: Mindfulness, Distress Tolerance, Emotion Regulation and Interpersonal Effectiveness.

Linehan recommends, as a minimum DBT training standard, that therapists should attend at least one of the DBT Intensive Training Programs in which they attend seminars for one week, spend six months implementing a program and then return for another week of seminars and feedback. In addition, continued program oversight or consultation is recommended with someone experienced in DBT. There is presently no licensing authority regulating certification in DBT. Linehan's group has a website where they post resource tools for clinicians and consumers.

Conclusions and Recommendations

DBT is effective in the treatment of chronically parasuicidal patients (multiple suicide gestures, attempts, threats, self-injurious behaviors or inpatient admissions). Other potential indications that are currently under investigation include BPD opiate-use disorder, stabilization of eating disorders, posttraumatic stress disorder, dissociative disorders, traumatic brain injuriesand BPD-in crisis.

Once approved by an MHN Medical Director, MHN authorizes DBT for the treatment of patients identified as chronically para-suicidal. The treatment authorization could last from 3 months to a year. Outpatient DBT treatment programs should include: 1) Program oversight by a senior clinician who has completed the Linehan training; 2) individual therapy, 3) group skills training, 4) a consult team for the therapists, and 5) medication management as needed. Treatment should occur at a minimum 3-5 times a week. While authorization would typically be issued for the expected duration of the program, MHN care managers periodically evaluate treatment progress and remain available for aftercare planning.

Website Resources

http://blogs.uw.edu/brtc/publications-articles-on-dialectical-behavior-therapy-dbt/

http://www.behavioraltech.com/resources/tools_clinicians.cfm

References

1: Nelson-Gray RO, Keane SP, Hurst RM, Mitchell JT, Warburton JB, Chok JT, Cobb AR. A modified DBT skills training program for oppositional defiant adolescents: promising preliminary findings. Behav Res Ther. 2006 Dec; 44(12): 1811-20.

 

2: Lynch TR, Cheavens JS, Cukrowicz KC, Thorp SR, Bronner L, Beyer J. Treatment of older adults with co-morbid personality disorder and depression: a dialectical behavior therapy approach.

Int J Geriatr Psychiatry. 2006 Nov 10.

3: Brassington J, Krawitz R. Australasian dialectical behavior therapy pilot outcome study: effectiveness, utility and feasibility. Australas Psychiatry. 2006 Sep; 14(3): 313-9.

4: Brazier J, Tumur I, Holmes M, Ferriter M, Parry G, Dent-Brown K, Paisley S. Psychological therapies including dialectical behavior therapy for borderline personality disorder: a systematic review and preliminary economic evaluation. Health Technol Assess. 2006 Sep; 10(35): iii, ix-xii, 1-117.

5: Bray S, Barrowclough C, and Lobban F. The social problem-solving abilities of people with borderline personality disorder. Behav Res Ther. 2006 Aug 16.

6: Kroger C, Schweiger U, Sipos V, Arnold R, Kahl KG, Schunert T, Rudolf S, Reinecker H. Effectiveness of dialectical behavior therapy for borderline personality disorder in an inpatient setting.

Behav Res Ther. 2006 Aug; 44(8): 1211-7.

7: Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006 Jul; 63(7): 757-66.

8: Kenedi CA, Lynch TR. Dialectical behavior therapy for clients with HIV. Focus. 2006 Jul; 21(7): 1-6.

9: Osborne UL, McComish JF. Borderline personality disorder: nursing interventions using dialectical behavioral therapy. J Psychosoc Nurs Ment Health Serv. 2006 Jun; 44(6): 40-7. Review.

10: Lynch TR, Chapman AL, Rosenthal MZ, Kuo JR, Linehan MM. Mechanisms of change in dialectical behavior therapy: theoretical and empirical observations. J Clin Psychol. 2006 Apr; 62(4): 459-80.

11: Hazelton M, Rossiter R, Milner J. Managing the 'unmanageable': training staff in the use of dialectical behavior therapy for borderline personality disorder. Contemp Nurse. 2006 Feb-Mar; 21(1): 120-30.

12: Comtois KA, Linehan MM. Psychosocial treatments of suicidal behaviors: a practice-friendly review. J Clin Psychol. 2006 Feb; 62(2): 161-70. Review.

13: Frederick JT, Comtois KA. Practice of dialectical behavior therapy after psychiatry residency.

Acad Psychiatry. 2006 Jan-Feb; 30(1): 63-8.

14: Conason AH, Oquendo MA, Sher L. Psychotherapy in the treatment of alcohol and substance abusing adolescents with suicidal behavior. Int J Adolesc Med Health. 2006 Jan-Mar; 18(1): 9-13.

15: House AS. Increasing the usability of cognitive processing therapy for survivors of child sexual abuse. J Child Sex Abus. 2006; 15(1): 87-103.

16: Miller AL, Rathus JH, Linehan MM and Swenson, CR, Dialectical Behavior Therapy with Suicidal Adolescents. Guilford Press, New York, 2006.

17: Safe, DL, Telc, CF and Agres WS: Dialectical behavior therapy for bulimia nervosa. Am J Psych: 158: 632-634, 2001.

18: Telch CF, Agra, WS and Linehan MM: Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology: 69: 1016-1069, 2001.

19: Linehan MM, Dimeff LA, Reynolds SK, Comtois KA, Welch SS, Heagerty P and Kivlaha DR: Dialectical behavior therapy versus comprehensive validation plus 12-step for the treatment of opiod dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13-26, 2002

20: van den Bosch LMC, Verheul R, Schippers GM and ven den Brink W: Dialectical behavior therapy of borderline patients with and without substance use problems: Implementations and long-term effects. Addictive Behaviors, 27(6), 911-923, 2002

21: McQuillan A, Nicastro R, Guenot, F, Girard M, Lissner C and Ferrero F, Intensive dialectical behavior therapy for outpatients with borderline personality disorder who are in crisis. Psychiatric Services, 56(20: 193-197, Feb 2005.

22: Linehan MM, DBT Skills Training Manual, 2nd Edition (2014) Guilford Press.

Effective Date: 2/6/2012
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Harm reduction is a philosophy of public health. Harm reduction policies and programs are part of both prevention programs and an attitude about treatment. The term harm reduction has not been defined by an official body and as a result is used with a variety of different interpretations. The World Health Organization uses the term "harm reduction in the sense of preventing adverse consequences of drug use without setting out primarily to reduce drug consumption."1 Essentially the harm reduction view of minimizing the consequences associated with use of alcohol, tobacco, or other drugs has led to the development of two applications. One application of the harm reduction philosophy resulted in the development of the secondary prevention programs and initiatives. There are a number of well-established programs and initiatives that have proven to be successful in reducing the health, social, and economic consequences of drug/alcohol use without necessarily reducing drug/alcohol consumption.2 Examples include needle-exchange programs for IV drug users; designated driver program; training programs for individuals who serve alcoholic beverages; dispensing free nicotine patches; and methadone maintenance. As secondary prevention these programs are effective and generally accepted as a means of preventing/diminishing health consequences associated with the targeted substances but not necessarily diminishing use of these agents. MHN supports the use of these harm reduction methodology such as methadone or Suboxone maintenance in conjunction with active participation in recovery programs and community support groups.

The second application of these concepts aims to address individuals seeking substance use disorder treatment. Some harm reductionists argue that some people will always engage in high-risk behaviors such as substance abuse. Therefore, rather than abstinence as the goal of substance abuse treatment, treatment goals are set by the clinician and the patient, with the patient setting the specific goals. This treatment model is predicated on the belief that one can reduce the potential harm associated with substance abuse without attempting to prohibit the behaviors.3 While harm reduction as used in the first application has been extensively proven as effective as a secondary prevention model, there is no published evidence indicating the use of the second application for individual treatment has any efficacy. The belief that giving the substance abuser the pros and cons of using or abstinence they would then be in a position of making their own decision would appear to be contradictory and at odds with mainstream principles of addiction and its treatment, as well as, the disease model of substance use disorders. Some harm reduction supporters use the success of such programs as methadone maintenance, as a supporting argument of why the same concepts work in individual treatment. MHN does not support the application of harm reduction to individual treatment without any clinical evidence or peer reviewed studies supporting this perspective.

WHO, Expert Committee on Drug Dependence. WHO Technical Report Series (28th Report). Geneva, Switzerland: WHO.

Harm Reduction as an Approach to Treatment, Wodak A. American Society of Addiction Medicine Textbook, 2003; Chapter 10:533-541.

www.wikipedia.com

Additional information:

Schukit M; Drug and Alcohol Abuse5th ed. 2000; Chapter 16:355-357.

Galanter M & Kelber H; APA Press Textbook of Substance Abuse Treatment1997; Chapter 20: 285-286, 292.

 

Effective Date: 05/03/2007
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Managed Health Network (MHN) has adopted the following policy recommendations of the American Society of Addiction Medicine Board of Directors as MHN Guidelines:

Opioid detoxification alone is not a complete treatment of opioid addiction. ASAM does not support the initiation of acute opioid detoxification intervention unless it is part of an integrated continuum of services that promote ongoing recovery from addiction.

Ultra-Rapid Opioid Detoxification (UROD) is a procedure with uncertain risks and benefits, and its use in clinical settings is not supportable until a clearly positive risk-benefit relationship can be demonstrated. MHN does not cover UROD.

Although there is medical literature describing various techniques of Rapid Opioid Detoxification (ROD), further research into the physiology and consequences of ROD should be supported so that patients may be directed to the most effective treatment methods and practices.

Prior to participation in any particular modality of opioid detoxification, a patient should be provided with sufficient information by which to provide informed consent, including information about the risks of termination of a treatment plan of prescribed agonist medications such as methadone or buprenorphine, as well as the need to comply with medical monitoring of their clinical status for a defined period of time following the procedure to ensure a safe outcome. Patients should also be informed of the risks, benefits and costs of alternative methods of treatment available.

The full ASAM Policy Statement can be found on line:

http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2011/12/15/rapid-and-ultra-rapid-opioid-detoxification

 

Effective Date: 01/09/2007
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

 

MHN recognizes that children and adolescents have special conditions and treatment needs that are different from those of adults. Comprehensive treatment for this population requires extra resources to provide the following:

  • A nurturing environment suitable for this age group;
  • Proper facilities to pursue age-related activities;
  • Access to an appropriate educational program; and
  • Family involvement in treatment.

Learning and attention disorders are treated more appropriately with educational, family and medical interventions, if this is a covered benefit, rather than hospitalization.

Therapy at any level for children and adolescents requires a thorough evaluation of the family and/or support system dynamics, including a careful search for evidence of physical or sexual abuse or substance use disorder.

Anti-social values or attitudes for which authoritarian restraint by parents or the juvenile justice system is appropriate may commonly drive disruptive behavior in adolescents. In other words, disruptive or sociopathic behavior in adolescents is not by itself a sufficient criterion for a mental disorder in this population.

 

Effective Date: 01/09/2007
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

MHN is committed to helping its members access the best possible care. This statement recognizes that various aspects of patient choice and culture play a role in treatment success. One aspect of culture relates to specific types of employment that may impact a member's willingness to accept treatment and also the need for treatment programs that are specifically prepared to address issues in unique employment populations. MHN understands that within our client population these unique groups exist, and that they require special attention in developing and selecting resources for treatment.

Examples of such highly specialized groups include members who work in law enforcement and health care. Law enforcement officials are at risk for behavioral health conditions including substance abuse issues. It is difficult for members who work in law enforcement to participate in local treatment programs because their ability to function in their jobs can be compromised when they are treated in the same setting as the citizens they either serve, or the individuals they arrest. Recognizing that, MHN is aware that a number of substance use disorder treatment programs are specifically designed to accept and treat law enforcement officers. Healthcare professionals face similar challenges in terms of appropriate treatment settings. In some states there are diversion programs specifically designed to treat licensed healthcare professionals. When that resource is not available, an alternative specialized program must be considered. In all of these programs, special attention is paid to the unique nature of the individuals requiring treatment.

MHN's policy is to authorize care at programs prepared to treat special populations such as healthcare professionals and law enforcement officials for members of those groups who are willing to accept treatment. MHN recognizes that some of these programs may not currently be part of MHN's provider network; however, in situations where MHN is seeking treatment for a specialized individual, MHN will make every effort to develop a single case agreement (SCA) with the facility and if possible bring that facility into the MHN network. This effort to bring the program into the network will occur whether the program is for MHN's full population or specialized groups only. When MHN recognizes the need of a specific group member for this type of treatment, MHN will treat this program as in network whether the program completes an SCA, joins the network, or chooses to remain out of network.

MHN is committed to obtaining the best possible outcomes in treatment for all of its members and recognizes that there will need to be specific and unique treatment management for highly specialized groups. The initial groups falling within this policy include law enforcement officers, penal system guards and healthcare professionals. MHN may add to this list as needed by bringing forward other groups to be approved by the MHN Clinical Leadership Committee and then added to this policy.

Effective Date: 7/24/2007
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

The MHN provider network has two different levels of detoxification programs, acute and subacute. The majority of subacute detox programs are part of Substance Use Disorder (SUD) residential treatment facilities. Below we define acute from subacute detox and what we require of each to join our network.

Acute detox programs:

  • Acute inpatient detox
  • Acute inpatient detoxification is an organized service delivered by medical and nursing professionals that provides for 24-hour medically directed evaluation and withdrawal management in an acute care inpatient setting Services are delivered under a defined set of physician-approved policies and physician-managed procedures or medical protocols. This level of care provides care to patients whose withdrawal signs and symptoms are sufficiently severe to require primary medical and nursing care services. Twenty-four hour observation, monitoring and treatment are available. 1

The acute care setting can be:

  • An acute care general hospital or an acute care psychiatric hospital with access to the full services of an acute care general hospital;
  • An appropriately licensed chemical dependency specialty center with acute care medical and nursing staff and life support equipment;
  • An acute addiction treatment unit in an acute care general hospital.

While legislative and geographical variances may exist, at a minimum these programs should include:2

  • A thorough substance evaluation must be performed in order to assess an individual's withdrawal potential. Assessment should include not only the all of the substances used, including age at onset of use, amounts, routes, frequency, changes in patterns of use, and periods of abstinence. In addition, the medical history should include past withdrawal experiences, complications, and possibility of seizures.
  • Nursing assessment within 8 hours and nursing staff observation 24 hours/day.
  • Medical history and physical examination within 24 hours.
  • Psychosocial assessment within 48 hours.
  • Toxicology screen within 4 hours, subsequent as needed.
  • Vital signs every 2 to 4 hours.
  • Clinical assessment at least 1 time/day.
  • Psychiatric consult as needed.
  • Neurologic/ Neuropsychiatric consult as needed.
  • Discharge plan initiated on admission.

Ambulatory (outpatient detoxification):

Detoxification can also be done on an outpatient basis, usually as part of a chemical dependency partial hospital or intense outpatient program, and while legislative and geographical variances may exist, at a minimum these programs should include:1,2

Programs are staffed by physicians and nurses, who are essential to the type of service being offered; however, they need not be present at all times (in states where physician assistants or nurse practitioners are licensed physician extenders, they may perform the duties designated for a physician).

Medical history, physical examination, and medical clearance on first day or prior to start of treatment, specifically ruling out a history consistent with prior withdrawal related seizures, delirium tremens, evidence of dementia or organ failure.

Substance evaluation, initial on the first day, subsequent as needed.

Nursing assessment on the first day.

Psychosocial assessment on the first day or prior to start of treatment.

Clinical assessment each visit.

Toxicology screen initial within 4 hours, subsequent as needed (random drug screens should be part of any outpatient detox and/or treatment program).

Discharge plan initiated on admission.

Medical consultation is readily available in emergencies.

Access to psychiatric consultation.

Direct affiliation with other levels of substance use care, as well as, general and psychiatric services (levels of care).

 

Subacute Detoxification:

This is an appropriately licensed organized free standing service that may be delivered by appropriately trained staff, who provide 24-hour supervision, observation and support for patients who are intoxicated or experiencing withdrawal. Specific effort is made before admission to rule out a history consistent with prior withdrawal related seizures, delirium tremens, evidence of dementia or organ failure. The full resources of a medically monitored inpatient detoxification service are not offered at this level of care. 1

All programs need to have established clinical protocols to identify patients who are in need of medical services beyond the capacity of the facility and to transfer such patients to more appropriate levels of care.

Able to arrange for appropriate laboratory and toxicology tests.

Programs are staffed by appropriately credentialed personnel who are trained and competent to implement physician-approved protocols for patient observation and supervision.

Detox is designed explicitly to safely detoxify patients without the need for ready on-site access to medical personal.

Medical evaluation and consultation is available 24 hours a day.

All clinicians who assess and treat patients are able to obtain and interpret information regarding the needs of the patients. This includes knowledge of:

Signs and symptoms of alcohol and other drug intoxication and withdrawal states.

Appropriate treatment and monitoring of these intoxication or withdrawal states.

Facilities that supervise self-administered medications have appropriately licensed or credentialed staff and policies and procedures accordance with state and federal law.

Staff assure that the patients are taking medications according to physician prescription and legal requirements.

Daily clinical services to assess and address needs of each patient including medical services, individual and group therapies, and withdrawal support.

Subacute residential detoxification is generally characterized by its emphasis on peer and social support.

Facilities that do not meet the above criteria for subacute detox level of care could still be accepted into the MHN network, but for a different level of care; for example, as a SUD residential treatment program, assuming they are licensed and meet MHN criteria for this level of care.

 

1 ASAM Placement Criteria, Second Edition Revised; ASAM 2001.

2 Chemical Dependency & Dual Diagnosis, Adult & Adolescent 2005 Interqual Level of Care. McKesson Health Solutions.

 

Effective Date: 7/12/2007
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Wilderness programs are services that attempt to help adolescents with behavioral problems by taking the teens into the wilderness and exposing them to an outdoor survival skills experience. MHN does not recognize the wilderness experience as evidence-based behavioral health treatment. In addition, MHN feels that this type of program exposes teens to potentially life threatening risks that are not required to treat the underlying behavioral conditions.

Requests for Wilderness Programs are denied on an administrative basis, because they are not recognized by MHN as a treatment service.

9.3 Treatment Guidelines

1. CMS National and Local Coverage Determinations

Effective Date: 06/19/2014
Date of Last Revision: 06/19/2017
Date of Last Review: 06/19/2017

MHN provides coverage for medically necessary treatment of mental health and substance use disorders and bases all decisions on InterQual Level of Care Criteria, MHN internal criteria, and the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), as appropriate. MHN's Business Compliance liaisons in the National Clinical Operations department review all CMS coverage determinations and immediately communicate any changes, in writing, to the service teams. MHN policies and procedures and/or training documents will reflect operational guidelines relating to CMS coverage determinations. Please see CMS link below for updated information.

http://www.cms.gov/medicare-coverage-database

 

2. Guidelines Regarding Dual/Multiple Relationships with Patients

Effective Date: 07/20/2006
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Managed Health Network (MHN) recognizes that the relationship between practitioner and patient is central to the treatment process and is an important component to the patient's healing. The practitioner's influence in this relationship, however, also has the potential of becoming exploitative and/or harmful. To prevent harm to patients caused by relationships that interfere with treatment, MHN expects practitioners to conform to the following standards:

Dual or multiple relationships: In psychotherapy, a dual or multiple relationship exists when the practitioner relates to a patient in another context (e.g., financial, business, social, or other activities) that also involves a personal relationship. Such dual or multiple relationships can occur either simultaneously with treatment or during a reasonable period of time following termination. Practitioners will not engage in such relationships with patients if there is a risk of exploitation or harm to the patient. Practitioners will also avoid dual relationships by not accepting as patients people they supervise and by not supervising individuals whom they have formerly had as patients. MHN recognizes that not all dual relationships are harmful and that some cannot be avoided. In cases of unavoidable dual relationships, MHN expects practitioners to take appropriate precautions to ensure that there is no conflict of interest, exploitation, or factors that would impair professional judgment. It is the practitioner's responsibility to set clear, appropriate, and culturally sensitive boundaries to protect patients' well-being.

Sexual relationships: A sexual relationship (including sexual intercourse, contact, or intimacy) with a patient, patient's relative, or an individual with whom the patient is interpersonally close, is prohibited during the course of treatment and for a period of at least two years following cessation of professional services. Practitioners will also not accept as patients individuals with whom they have formerly engaged in sexual intimacies. MHN further discourages practitioners from engaging in sexual relationships with persons over whom they have supervisory, evaluative, or other authority. The latter relationships are prohibited if they pose a risk to patient care or are prohibited by regulations related to a practitioner's license.

Conflicting roles: When practitioners provide services to two or more individuals who have a relationship with each other (e.g., couples, family members), there is a risk of conflicting roles. In such cases, the practitioner makes every effort to avoid role conflict by clarifying his/her role to all parties involved and taking appropriate action to minimize any conflict of interest. This issue is of particular concern in legal proceedings (e.g., divorce, custody disputes). Although a prior professional relationship does not preclude a practitioner from testifying as a fact witness or as to services provided, the practitioner must take into account ways in which the prior relationship might affect professional objectivity. Prior to offering testimony, the practitioner must disclose the potential conflict to all relevant parties.

 

3. Guidelines for Outpatient Care of Children and Adolescents

Effective Date: 10/31/2006
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Parent(s) or guardian(s) are being educated and are participating actively in the treatment process, where appropriate. Efforts are being made to enhance family functioning and the ability of parents or guardians to help manage the patient's psychiatric disorder.

Outpatient psychotherapy may be used to address acute symptoms or to help patients maintain their level of function in the presence of chronic illness. Psychotherapy should have clear and measurable goals of treatment that will reduce the risk of danger to self and others, optimize functioning and return the patient to his/her baseline developmental tract, and reduce the likelihood of requiring future treatment at higher levels of care.

Medical necessity could be evaluated through attempts to increase the time interval between visits.

 

4. Guidelines for When a Therapist is Seeing More Than One Family Member at a Time in Outpatient Treatment

Effective Date: 01/09/2007
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Psychotherapists shall carefully consider the potential conflict that may arise between the family unit(s) and each individual. Psychotherapists should clarify at the commencement of therapy which person or persons are clients, and the nature of the relationship(s) the therapist will have with each person involved in the treatment. MHN recommends that a therapist have individual session with one member only as an adjunct to family treatment, and ongoing individual therapy for more than one family member should not, as a rule be authorized. If multiple members of the family are in need of treatment, there should be a family therapist to treat the unit and individuals in the family in need of ongoing treatment, should be referred to other MHN providers who should collaborate regularly with the designated primary therapist treating the family.

 

5. Guidelines for When a Therapist is Seeing a Member More Than Once Weekly in Outpatient Treatment

Effective Date: 07/20/2006
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

It is MHN's position that more than one session per week of outpatient therapy is for short term use only. It should be driven by clinical needs and used on a brief basis at the treating provider's discretion to address situations of heightened clinical acuity or scheduling logistics. Provision of more than one session a week does not need to be approved by MHN; however, the treating provider's use of this increased intensity of care may be reviewed if the case is identified as an outlier as a result of MHN population management reports, or a result of provider's practice style/orientation versus a specific member's clinical treatment needs. Outpatient psychotherapy utilization patterns exceeding 16 sessions in 12 weeks shall trigger a clinical inquiry to determine medical necessity for higher than expected intensity of treatment.

 

1. Medical Necessity

Effective Date: 07/20/2006
Date of Last Revision: 05/08/2017
Date of Last Review: 05/08/2017

Health Net's National Medical Advisory Council (MAC) has provided clarification of terms used in its medical policies for investigational or experimental and not medically necessary and not investigational. Health Net medical policies are reviewed annually and revised to better clarify whether services are investigational or medically necessary. This clarification should enable providers to more quickly determine whether a service is considered investigational and, therefore, submit the request for a proposed service timely to Health Net for utilization management (UM) review and determination, based on the terms of the provider's contract.

These definitions do not apply to Medi-Cal or Medicare Advantage (MA) plans. Health Net follows the California Department of Health Care Services (DHCS) and Centers for Medicare and Medicaid Services (CMS) definitions, respectively, for those members.

 

PURPOSE OF HEALTH NET MEDICAL POLICIES

Medical policies provide guidelines for determining medical necessity for specific procedures, equipment and services. All services must be medically necessary to be eligible for benefit coverage, unless otherwise defined in the member's benefits contract. The determination for coverage is also based on all of the terms of the individual member's benefits contract, including, but not limited to, eligibility at the time of service and description of covered benefits, limitations and exclusions. In some cases, a legal mandate may be applicable and may prevail over medical policy. To the extent there are any conflicts between medical policy guidelines and applicable benefit contract language, the benefit contract language prevails. Medical policy is not intended to override the health insurance policy that defines the

member's benefits, nor is it intended to provide medical advice or dictate to providers how to practice. If required, prior authorization must be obtained before services are rendered.

 

DEFINITIONS

Medically Necessary

Except where state or federal law or regulation, or members' health benefit contracts require a different definition, Health Net applies the following definition of medically necessary:

Health care services that a physician or other healthcare provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are:

  1. In accordance with generally accepted standards of medical practice;
  2. Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and
  3. Not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.
  4. For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or documented physician specialty society recommendations.

Investigational or Experimental

This definition is provided for illustrative purposes only. Consult the applicable health benefit plan contract (member's Evidence of Coverage) for the specific definition of investigational or experimental:

Investigational or experimental is used to describe a service (a medication, biological product, device, equipment, medical treatment, therapy, or procedure) that Health Net has determined is not presently recognized as standard medical care for a medically diagnosed condition, illness, disease, or injury, but which is being actively investigated for use in the treatment of the diagnosed condition, illness, disease, or injury. A service is considered experimental or investigational if it meets any of the following criteria:

  1. It is currently the subject of an active and credible evaluation (such as clinical trial or research) to determine:
    • Clinical efficacy;
    • Therapeutic value of beneficial effects on health outcomes;
    • Benefits beyond any established medical based alternative.
  2. It does not have final clearance from applicable governmental regulatory bodies, such as the United States Food and Drug Administration (FDA), and unrestricted market approval for use in the treatment of a specified medical condition or the condition for which authorization of the service is requested and is the subject of an active and credible evaluation.
  3. The most recent peer-reviewed scientific studies published or accepted for publication by nationally recognized medical journals do not conclude, or are inconclusive in finding, that the service is safe and effective for the treatment of the condition for which authorization of the service is requested.

Not Medically Necessary and Not Investigational

  1. Evaluation and clinical recommendations are assessed according to the scientific quality of the supporting evidence and rationale (such as national medical associations, independent panels or technology assessment organizations).
  2. A service is considered not medically necessary and not investigational if it meets any of the following criteria:
    • There are no studies of the service described in recently published peer-reviewed medical literature.
    • There are no active or ongoing credible evaluations being undertaken of the service, which has previously been considered not medically necessary.
    • There is evidence in published peer-reviewed medical literature that the service is not effective.
    • There are no peer-reviewed scientific studies published or accepted for publication by nationally recognized medical journals that demonstrate the safety or efficacy of the use of the service.
    • It is contraindicated.