Behavioral Health: Chemical Dependency/Substance Abuse Residential Treatment

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1 UTILIZATION MANAGEMENT GUIDELINE COVERAGE GUIDELINE CODING RELATED POLICIES SCOPE ADDITIONAL INFORMATION HISTORY Behavioral Health: Chemical Dependency/Substance Abuse Residential Treatment Number Effective Date February 10, 2015 Revision Date(s) 02/10/15; 01/01/15 Replaces N/A Coverage Guideline Chemical dependency/substance abuse residential treatment may be considered medically necessary when treatment is provided in a stand-alone chemical dependency/substance abuse/dual disorders facility that is licensed as a residential treatment or sub-acute treatment facility, in a chemical dependency/substance abuse/ dual disorders residential treatment unit within a licensed psychiatric residential treatment or sub-acute treatment facility, or in a chemical dependency/substance abuse/dual disorders residential treatment unit of a licensed hospital, and the criteria listed below are met. Criteria Severity of Illness Criteria for Chemical Dependency/Substance Abuse Residential Treatment Admission All of the following must be present: I. Chemical dependency or substance abuse (a DSM-5 Substance Use Disorder) other than for tobacco/nicotine, not in remission. II. Chemical dependency/substance abuse is out of control, including immediately prior to admission (i.e. no significant period of abstinence prior to admission), to the extent that the patient is unable to initiate or maintain abstinence, and prevent continued use or relapse, without a 24/7 contained, structured, supportive treatment setting. If transferring directly from an inpatient setting (chemical dependency, psychiatric, or medical), a detoxification setting, a crisis treatment center, psychiatric or eating disorders residential treatment, a wilderness or adventure or camping program or expedition, or from incarceration, this criterion was present immediately prior to admission to that setting, and would rapidly recur with discharge or release to a home or community setting. III. Harm to self or others (physical or medical) or serious and pervasive deterioration in functioning and/or self-care, due to substance use. OR, imminent probability of harm to self or others (physical or medical) or of serious and pervasive deterioration in functioning and/or self-care, without cessation of use. If transferring directly from an inpatient setting (chemical dependency, psychiatric, or medical), a detoxification setting, a crisis treatment center, psychiatric or eating disorders residential treatment, a wilderness or adventure or camping program or expedition, or from incarceration, this criterion was present immediately prior to admission to that setting, and would rapidly recur with discharge or release to a home or community setting. IV. At least one of the following must be present a. Poor or no awareness of, or outright denial of, her or his chemical dependency/substance abuse, the negative consequences of her or his chemical dependency/substance abuse, and/or the need to cease substance use and be abstinent, and/or the need for chemical dependency/substance abuse treatment. b. Significant difficulty cooperating with, or resistance or overt opposition to, chemical

2 dependency/substance abuse treatment. c. Poor or no recognition or utilization of the skills needed to prevent continued use or relapse. d. Active ongoing drug craving coupled with inability to delay immediate gratification. e. Poor or no recognition of relapse triggers, or inadequate skills to be able to prevent or interrupt the relapse process, and unable to use peer or community supports to prevent or stop relapse. f. Living environment and/or social network do not support abstinence, or actively undermine or sabotage abstinence, or are dysfunctional or toxic or physically dangerous to the extent that initiation and maintenance of abstinence are not feasible. g. Unable to cease use or maintain abstinence despite treatment in accessible less restrictive/intensive level(s) of care (partial hospitalization, intensive outpatient treatment, outpatient treatment). And the patient is medically and psychiatrically stable to the extent that inpatient medical, psychiatric, or chemical dependency treatment, or inpatient detoxification, is not needed, and the patient s existing medical and psychiatric needs can be appropriately managed in the residential treatment setting. Alternately, chemical dependency/substance abuse residential treatment admission may be appropriate when partial hospitalization or intensive outpatient treatment would be appropriate but the patient does not have reasonable geographic access to chemical dependency/substance abuse partial hospitalization or intensive outpatient treatment, and the patient does not have sober and supportive family or others to temporarily stay with in a location with reasonable geographic access to chemical dependency/substance abuse partial hospitalization or intensive outpatient treatment. Additional Criteria for Chemical Dependency/Substance Abuse Residential Treatment Admission All of the following must be met: 1. The primary purpose of the residential treatment admission is to develop sufficient coping skills and relapse prevention skills to be able to transfer to a less restrictive/intensive level of care (partial hospitalization, intensive outpatient treatment, outpatient treatment) without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical or medical) or imminent probability of serious and pervasive deterioration in functioning and/or self-care. 2. Sufficient improvement for transition to a less restrictive/intensive level of care (partial hospitalization, intensive outpatient treatment, outpatient treatment) is expected within a limited period of time (generally 30 to 45 days, or 60 to 90 days for clinically extenuating cases). 3. Residential treatment admission is not primarily due to court-ordered stay in the absence of criteria (I) through (IV) above. 4. The patient has sufficient cognitive capacity to participate in, utilize, and benefit from residential treatment. 5. If there have been one or more previous episodes of chemical dependency/substance abuse residential treatment, an explanation is provided of why previous residential treatment failed to be effective, or why improvement during residential treatment was not able to be maintained following discharge from residential treatment, and what is going to be different about another episode of chemical dependency/substance abuse residential treatment such that it is expected to result in improvement during treatment and sustained maintenance of improvement following discharge. 6. If there have been multiple previous episodes of chemical dependency/substance abuse treatment (any levels of care) with a pattern of relapsing after treatment, an explanation is provided of what is going to be different about another episode of treatment (residential this time) such that it is expected to result in maintenance of abstinence following discharge. 7. Admission to chemical dependency/substance abuse residential treatment is not due to transfer from another chemical dependency/substance abuse residential treatment facility. 8. The location of treatment is not an ASAM Level 3.1 facility. Level 3.1 facilities are 24/7 supportive living environments, e.g. sober living residences, not 24/7 treatment settings. Actual treatment services can be as few as 5 hours/week, and are not provided several hours daily as is the case with residential treatment. 9. The location of treatment is not any type of wilderness or adventure or camping program or expedition, boarding school or therapeutic boarding school, boot camp, military school or academy, group home, therapeutic home, or supported or alternative housing. 10. Residential treatment is not being utilized as an alternative to respite for family or community. 11. Residential treatment is not being utilized as an alternative to incarceration. 12. Residential treatment is not being utilized for long-term placement due to lack of available or adequate

3 sober and supportive living settings in the community. 13. Residential treatment admission is not taking place from a home or community setting after the patient has been on a waiting list for admission (this indicates that criteria (II) and (II) above are not present). Severity of Illness Criteria for Continued Stay At least one of the following must be present: 1. One or more of admission criteria (IV a) through (IV f) above must still be present in conjunction with insufficient development of coping skills and relapse prevention skills to be able to transfer to a less restrictive/intensive level of care (partial hospitalization, intensive outpatient treatment, outpatient treatment) without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical or medical) or imminent probability of serious and pervasive deterioration in functioning and/or self-care. However, clinical progress must also be evident. If the stay reaches thirty days without clinical progress, then beginning improvement must be evident within an additional seven days, followed by observable clinical progress every seven to ten days in the specific components of admission criterion (IV) that are preventing transfer to a less restrictive/intensive level of care. 2. Sufficient improvement for partial hospitalization, intensive outpatient treatment, or outpatient treatment has occurred, but a brief additional period (seven to fourteen days) of residential treatment is indicated (with or without passes see Intensity of Service Criteria below) to ensure that improvement can be maintained without significant decompensation. 3. Sufficient improvement for partial hospitalization, intensive outpatient treatment, or outpatient treatment has occurred, but a very brief additional period (up to seven days) of residential treatment is indicated to secure an appropriate living placement for a patient who will rapidly decompensate and be re-admitted if not discharged directly to such placement. 4. Maximum likely improvement has been achieved, there is little likelihood of further clinical improvement with continued residential treatment, but a very brief additional period (up to seven days) of residential treatment is needed to secure an appropriate placement for a patient who will rapidly decompensate and be re-admitted if not discharged directly to such placement. 5. Little or no improvement has been achieved, there is little likelihood of clinical improvement with continued residential treatment, but a very brief additional period (up to seven days) of residential treatment is needed to secure an appropriate placement for a patient who will rapidly be re-admitted if not discharged directly to such placement. 6. Sufficient improvement for partial hospitalization or intensive outpatient treatment has occurred, but the patient resides in or will be discharging to a location without reasonable geographic access to chemical dependency/substance abuse partial hospitalization or intensive outpatient treatment. In this case, a short additional period of continued residential treatment is appropriate to stabilize the patient sufficiently for discharge to outpatient treatment. 7. If the patient is stepping down to a less restrictive residential treatment unit, one or more of admission criteria (IV d) through (IV f) above must still be present in conjunction with insufficient development of coping skills and relapse prevention skills to be able to transfer to partial hospitalization, intensive outpatient treatment, or outpatient treatment without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical or medical) or imminent probability of serious and pervasive deterioration in functioning and/or self-care; or, continued stay criterion (f) immediately above must be present. Additional Criteria for Continued Stay All of the following must be met: 1. The purpose of the residential treatment stay continues to be development of sufficient coping skills and relapse prevention skills to be able to transfer to a less restrictive/intensive level of care (partial hospitalization, intensive outpatient treatment, outpatient treatment) without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others (physical or medical) or imminent probability of serious and pervasive deterioration in functioning and/or self-care. 2. The residential treatment facility/program must be able to (1) describe clinical evidence of the risk of relapse outside of the residential treatment setting, (2) identify the specific coping skills and relapse prevention skills that the patient lacks or has not yet adequately developed, or the specific elements of a relapse prevention plan that need to be completed, and (3) explain what specifically is being done to help

4 the patient develop those skills or complete those missing elements. 3. There must be reasonable likelihood, based on clinical information, that continued residential treatment has the potential to result in (further) clinical improvement. Sufficient improvement for transition to a less restrictive/intensive level of care (partial hospitalization, intensive outpatient treatment, outpatient treatment) is still expected within a limited period of time (generally 30 to 45 days, or 60 to 90 days for clinically extenuating cases). Continued inability to improve will generally be considered as evidence that continued residential treatment no longer has the potential to result in (further) clinical improvement, and is therefore no longer indicated (except for severity of illness continued stay criteria (4) and (5) above). 4. The patient is compliant with program rules and treatment recommendations, is attending most or all treatment activities, is demonstrating recognition of her or his chemical dependency/substance abuse, is demonstrating commitment to treatment and to abstinence, is demonstrating motivation to improve, and is actively participating in treatment and attempting to utilize treatment to achieve clinical progress. However, if admission criteria (IV a) and/or (IV b) are present and therefore impeding compliance, engagement and participation, commitment to abstinence, and/or utilization of treatment, some degree of improvement in these areas must be evident no later than thirty days after admission, with progressive improvement for the remainder of the stay. 5. Co-morbid psychiatric or medical symptoms or disorders, if present, are controlled or stable enough for the primary focus of treatment to be the patient s Substance Use Disorder, or, if interfering with treatment and progress, are being evaluated and treated appropriately and without delay. 6. Continued residential treatment is not primarily for containment or to prevent regression because there has been minimal or no improvement after a reasonable period of time (generally thirty days) and there is little likelihood of improvement with continued residential treatment (except for severity of illness continued stay criterion (5) above). 7. Continued residential treatment is not primarily for containment or to prevent regression because clinical progress has stalled, or a new or chronic baseline has been reached, or maximum likely improvement has been achieved, and there is little likelihood of further improvement with continued residential treatment (except for severity of illness continued stay criterion (4) above). 8. Continued residential treatment is not primarily due to a pre-determined fixed length of stay, a requirement that patients complete a pre-determined program, or a requirement that patients reach a certain level in a level program. Lengths of stay, treatment plans, and treatment goals must be individualized for each patient. 9. Continued residential treatment is not primarily to complete certain steps or reach a certain step of the Twelve Steps. The Twelve Steps were not developed as goals or indicators of progress for residential treatment. 10. Continued residential treatment is not primarily due to the presence of risk of relapse. Most patients will be at some degree of risk of relapse on an ongoing basis regardless of the treatment setting or living setting. The appropriate level of treatment is determined by ability to manage the risk of relapse, not by the mere the presence of risk of relapse. 11. Continued residential treatment is not primarily due to lack of adequate family, living environment, peer, community, or other external supports when the patient has otherwise improved sufficiently for partial hospitalization, intensive outpatient treatment, or outpatient treatment. Inadequate family, living environment, peer, community, or other external supports, including when admission criteria (IV f) is present, should be identified early in the residential treatment stay and actively worked-on throughout the stay such that, by the time the patient has improved sufficiently for partial hospitalization, intensive outpatient treatment, or outpatient treatment, family/living environment/ peer/community/other external supports are not impediments to discharge, or, alternative placement has been sought and secured, or will be sought and secured within seven days as per severity of illness continued stay criteria (3), (4), or (5) above). 12. Continued residential treatment is not primarily due to lack of a place for the patient to reside (except for severity of illness continued stay criteria (3), (4), or (5) above) Continued residential treatment is not primarily due to waiting for a placement to be identified or secured (except for severity of illness continued stay criteria (3), (4), or (5) above) Continued residential treatment is not primarily due to waiting for funding for a placement (except for severity of illness continued stay criteria (3), (4), or (5) above). 15. Continued residential treatment is not primarily due to waiting for application to, acceptance by, bed availability at, funding for, or transfer to a halfway house or other sober living residence (except for severity of illness continued stay criteria (3), (4), or (5) above) Continued residential treatment is not primarily due to waiting for acceptance by, bed availability at, funding for, or transfer to another treatment setting, e.g. a psychiatric or eating disorders RTC, (except for severity of illness continued stay criteria (3), (4), or (5) above) Continued residential treatment is not primarily due to waiting for the date of enrollment or starting in a

5 school, vocational, treatment, or other program. 18. Continued residential treatment is not primarily due to a court-ordered stay in the absence of one of severity of illness continued stay criteria (1) through (5) above. 19. Continued residential treatment is not primarily due to waiting for a discharge plan to be determined or worked-on or completed. 20. Continued residential treatment is not primarily due to waiting for a court-order or approval in order to be released. 21. Continued residential treatment is not primarily due to unavailability or refusal of family, friends, or other persons to pick-up the patient. 22. Continued residential treatment is not primarily due to unavailability of, or difficulties or delays in arranging for, transportation to home/community, another treatment facility, a placement, or other discharge location. 23. Continued residential treatment is not primarily because of a pending change in or uncertainty about family structure, e.g. a pending or possible separation or divorce, or for children and adolescent patients, a pending change in or uncertainty about custody or guardianship. 24. Continued residential treatment is not primarily for respite for family or community. 25. Continued residential treatment is not primarily to delay or avoid incarceration. 26. Continued residential treatment is not primarily due to patient or family non-compliance with treatment orders, treatment recommendations, or treatment activities, inadequate or non-participation in treatment, or inadequate/absent participation in discharge planning. 27. Continued residential treatment is not primarily because of post-acute withdrawal syndrome (PAWS) symptoms. PAWS can last for up to 20 months (well beyond reasonable lengths of stay for residential treatment), and is manageable on an outpatient basis. If PAWS is a significant problem for a patient, the residential treatment program is expected to provide adequate education regarding the recognition and self/outpatient-management of PAWS. 28. Continued residential treatment is not primarily because the patient has been able to access and use substances (inside or outside of the facility; on or off of facility grounds) while in residential treatment. In such cases, it is appropriate to determine if the patient meets criteria for and is appropriate for inpatient treatment, or if the patient is not yet sufficiently ready for abstinence and treatment. 29. Continued residential treatment is not primarily to work on long-term goals, or for intensive work on longstanding or long-term issues. Although long-standing or long-term issues may be contributory to a patient s Substance Use Disorder, and long-term goals may be relevant in the treatment of a Substance Use Disorder, residential treatment is not intended to be a long-term process, and much of the work will need to continue post-residential treatment. Residential treatment should generally be able to be completed in 30 to 45 days, or 60 to 90 days for clinically extenuating cases). 30. Continued residential treatment is not primarily for psychotherapeutic work that has the potential to cause a worsening of symptoms (e.g. some forms of trauma work, even if past trauma is believed to be contributory to the patient s Substance Use Disorder). 31. Continued residential treatment is not primarily to ensure that a certain level of improvement can be maintained for an extended period of time prior to discharge. Seven to fourteen days of a level of improvement that can be managed at a less restrictive level of care is considered to be sufficient for discharge from residential treatment, as per continued stay criterion (b) above. Note: Sufficient improvement for transition to partial hospitalization, intensive outpatient treatment, or outpatient treatment refers to sufficient improvement for a less restrictive level of care in conjunction with a halfway house or other sober living residence unless (1) a halfway house or other sober living residence is not accessible for the patient, (2) home or an alternate family or friend setting is available that can fully support maintenance of abstinence, or (3) there are compelling clinical reasons for discharge to home or to a specific family or friend setting. Intensity of Service Criteria for Chemical Dependency/Substance Abuse Treatment Admission and Continued Stay All of the following must be present: 1. Trained and credentialed clinical staff on-site 24/7. 2. Timely access to psychiatric care and medical care when needed. 3. A comprehensive, individualized, realistic treatment plan that focuses primarily on (1) development of sufficient coping skills and relapse prevention skills to be able to transfer to a less restrictive/intensive level of care (partial hospitalization, intensive outpatient treatment, outpatient treatment) without immediate risk of relapse, or resumption of continued use, that would create imminent probability of harm to self or others

6 (physical, medical, severe functional); (2) addressing any psychosocial or environmental factors that are preventing or impeding the development of appropriate coping skills and relapse prevention skills; and (3) addressing any psychiatric or medical co-morbidities that are preventing or impeding the development of appropriate coping skills and relapse prevention skills. a. The treatment plan and the treatment provided must be individualized for the patient and not determined by any type of standardized program, any pre-set number of program days, or reaching a certain chronological age. b. If ancillary evaluation (e.g. psychiatric or medical evaluation) is required prior to being able to complete a comprehensive treatment plan, all necessary ancillary evaluations and the comprehensive treatment plan must be completed no later than fourteen days after admission. 4. The primary foci of treatment and treatment interventions at all times are (1) the patient s Substance Use Disorder, with particular emphasis on the specific coping skills and relapse prevention skills that the patient lacks or has not yet adequately developed that are preventing discharge to a less restrictive/intensive level of treatment, and (2) any ancillary factors (psychosocial, environmental, psychiatric, medical) that are preventing or impeding the development of those skills or otherwise preventing discharge to a less restrictive/intensive level of treatment. 5. Significant psychiatric co-morbidities are not a primary or major focus of treatment, but are addressed as necessary to cease or minimize interference with primary treatment of the patient s Substance Use Disorder. Unless medically contraindicated or there is a valid clinical reason for a delay, non-addictive psychotropic medication must be rapidly initiated for psychiatric conditions or symptom constellations that are interfering with chemical dependency/substance abuse treatment and are known to be potentially medication-responsive. Failure to access consultative psychiatric resources in a timely fashion when necessary is not by itself adequate grounds for extending length of stay. 6. For adolescent patients, and for patients 18 and older who are residing with a parent or parents, there must be a minimum of one family therapy session on-site weekly, with a greater frequency (e.g. two to three times weekly) when clinically indicated (e.g. in some cases in which admission criteria (IV f) is present), unless it can be clearly demonstrated that family therapy/treatment involvement would adversely impact clinical outcome. Telephonic or video sessions may be utilized in lieu of on-site sessions if the family resides more than a three hour one-way drive from the facility (estimated driving time takes into account weather or other delays). When telephonic or video sessions are utilized in lieu of on-site sessions, increased frequency of sessions (e.g. two to three times weekly) may be required to compensate for the absence of on-site family work. Multi-family groups are not acceptable for meeting this requirement. 7. Concurrent medical or surgical problems, if significant or if potentially interfering with assessment or treatment, must be evaluated and treated in a timely fashion. Failure to access consultative medicalsurgical resources in a timely fashion is not by itself adequate grounds for extending length of stay. 8. If ongoing cravings for alcohol or opioids are impeding discharge to a less restrictive/intensive level of treatment, then there must be an evaluation by a physician or clinical nurse practitioner with addiction treatment experience for the potential usefulness of anti-craving medication. If such evaluation results in a strong recommendation for anti-craving medication, then such medication must be initiated without delay unless there are medical contraindications, and must be continued for the remainder of the stay unless intolerable adverse effects or medical contraindications develop. 9. An initial discharge plan must be formulated within seven days of admission. Subsequent to that, active, appropriate, realistic, comprehensive discharge planning must be initiated in a timely fashion and must continue throughout the residential stay until completed. Discharge planning may not be delayed until the patient is clinically ready for discharge. Discharge planning must include early identification of the level of care and/or services, provider types, and other resources that will be needed post-discharge, including sober living residences, and family and community supports and resources, as appropriate. There must be evidence of ongoing activity to locate and secure post-discharge treatment resources. Appropriate follow-up or post post-discharge facility treatment must be scheduled or arranged and must be timely. If discharge to a halfway house or other sober living residence is clinically optimal, or if discharge to home/family is otherwise not an option, then sober living residence or other alternative placement options (whichever is appropriate) must be rapidly identified, and there must be active efforts to locate and secure placement. The facility must take primary responsibility for carrying-out and completing discharge planning, and may not expect the patient or family/ guardians to seek and secure follow-up arrangements or placement beyond what the patient or family/guardians are realistically capable of doing and willing to do in a timely manner. The discharge plan may be modified if necessitated by a significant change in the patient s clinical condition or by failure to improve to the extent that had been anticipated. 10. Failure to improve within clinically expected timeframes must lead to a reassessment of the treatment plan and an appropriate revision of the treatment plan. 11. The patient must be involved in active treatment activities or interventions during a majority of waking

7 hours, 7 days/week (residential treatment is not for respite, relaxation, recreation, or rest). The following services must be provided throughout the residential stay: a. Staff supervision 24/7. b. Skilled nursing care available when needed 24/7. c. Clinical assessment at least once daily. d. Individual psychotherapy at least once weekly, and more frequently (e.g. two to three times weekly) when clinically indicated. e. Group psychotherapy and/or milieu therapeutic activities several hours daily. 12. If chemical dependency/substance abuse developed due to prescribed, non-prescribed, or illicit medication or drug use secondary to chronic pain, then treatment must include development or substitution of alternative pain management or pain tolerance techniques and strategies. 13. Therapeutic passes may be appropriate, when discharge is anticipated within one to two weeks and the discharge plan is for discharge to home or other community setting with follow-up via partial hospitalization, intensive outpatient treatment, or outpatient treatment, (1) for evaluating patients' readiness for discharge by assessing their ability to function at home and in the community, or (2) for providing a less-abrupt transition back to home and community (e.g. via partial day attendance at school or work). For adolescent patients, passes must be with a parent, guardian, custodian, or other responsible adult. A maximum of one or two successful partial day passes, full day passes, or overnight (1-2 nights) passes is sufficient, and discharge is then expected within seven days of completion. Passes which exceed these parameters will be considered to be conclusive evidence that residential treatment is no longer medically necessary. 14. Therapeutic passes may also be appropriate for attending off-site AA, NA, or similar meetings. Such passes may be appropriate as part of the treatment plan at various times during the course of residential treatment, or in preparing for discharge. Except for adult patients who are within one to two weeks of anticipated discharge, such passes must be with clinical staff or responsible non-using adult accompaniment regardless of the patient s age. Coding CPT Number Description Interactive complexity (List separately in addition to the code for primary procedure) Psychiatric diagnostic evaluation Psychiatric diagnostic evaluation with medical services Psychotherapy, 30 minutes with patient and/or family member Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychotherapy, 45 minutes with patient and/or family member Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Psychotherapy, 60 minutes with patient and/or family member Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure) Family psychotherapy (without the patient present) Family psychotherapy (conjoint psychotherapy) (with patient present) Multiple-family group psychotherapy Group psychotherapy (other than of a multiple-family group) Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time,

8 face-to-face Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report Neuropsychological testing (e.g., Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face Neuropsychological testing (e.g., Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report Related Guidelines / Policies Behavioral Health: Inpatient/Residential Detoxification Behavioral Health: Chemical Dependency/Substance Abuse Inpatient Treatment Scope Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. Additional Information References 1. D Mee-Lee et al, The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co- Occurring Conditions, Third Edition. The Change Companies, R Ries et al. The ASAM Principles of Addiction Medicine, Fifth Edition. Wolters Kluwer, American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing, History Date Reason 01/13/15 New Benefit Coverage Guideline, add to Mental Health section Chemical dependency/substance abuse residential treatment may be considered medically necessary when all criteria are met. 02/10/15 Interim update. Additional criteria added to indicate that treatment is not an alternative to incarceration or to be utilize as an alternative to respite for family/community and patient must be actively using prior to admission.

9 Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA) Premera All Rights Reserved.

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