1 WORKERS COMPENSATION PROTOCOLS WHEN PRIMARY INJURY IS PSYCHIATRIC/PSYCHOLOGICAL General Guidelines for Treatment of Compensable Injuries Patient must have a diagnosed mental illness as defined by DSM-5 that, by accepted medical standards, can be expected to improve significantly through medically necessary and appropriate therapy. The emotional impairment must be of such a degree to severely interfere with social, familial, or occupational functioning. For the purpose of determining medical necessity of care, medical necessity is defined as Services and supplies by a provider to identify or treat an illness that has been diagnosed. They are: A. consistent with the efficient diagnosis and treatment of a condition, and standards of good medical practice. B. required for other than convenience. C. the most appropriate supply or level of service. D. unable to be provided in a more cost effective and efficient manner; and E. unable to be provided elsewhere by a less intensive level of care. The evaluation and assignment of mental illness diagnosis must take place in a face-toface evaluation of the patient performed by a psychiatrist or doctoral level clinical psychologist. Presence of the illness(es) must be documented through the assignment of appropriate DSM-5 codes using published criteria. Whenever feasible and appropriate, psychiatric care and treatment should take place in an outpatient setting or the less intensive treatment setting able to meet the patient s needs. Structured outpatient programs are considered the treatment of first choice. Inpatient treatment is considered medically necessary when all less intensive levels of treatment have been determined to be unsafe or have been unsuccessful. The initial evaluation should include not only documentation of the diagnosis (DSM-5), but also an initial treatment plan, individualized goals for treatment, treatment modalities to be used, and discharge planning. A progress note documenting the provider s treatment, the patient s response to treatment, and the persistence of the problems that necessitate continued care despite treatment efforts, with the emergence of additional problems consistent with the initial diagnosis, must be written for each session of treatment. Documentation of disposition planning should be an integral part of each session note. Response, non-response or severe reactions to medications given must be recorded.
2 Continued Conditions That May Be Related to Work Injuries or Traumas A. Depressive disorders Except pre-menstrual dysphoric disorder B. Anxiety disorders 1. Except separation anxiety disorder 2. Except selective mutism 3. Except social anxiety disorder C. Trauma- and stressor-related disorders 1. Except reactive attachment disorder 2. Except disinhibited social engagement disorder D. Medication-induced movement disorders and other adverse effects of medication Conditions That May Not Be Related to Work Injuries or Traumas A. Neurodevelopmental disorders Except stereotypic movement disorder associated with environmental factors B. Schizophrenia spectrum and other psychotic disorders 1. Except brief psychotic disorder with marked stressor(s) 2. Except medication-induced psychotic disorder (if iatrogenic) C. Bipolar and related disorders Except medication-induced bipolar and related disorders (if iatrogenic) D. Obsessive-compulsive and related disorders E. Dissociative disorders F. Somatic symptom and related disorders Except conversion disorder G. Feeding and eating disorders H. Elimination disorders I. Sleep-wake disorders Except shift work type J. Sexual dysfunctions Except medication-induced sexual dysfunction K. Gender dysphoria L. Disruptive, impulse-control, and conduct disorders M. Substance-related and addictive disorders Unless iatrogenic in origin N. Neurocognitive disorders 1. Except medication-induced delirium 2. Except medication-induced major or minor neurocognitive disorder 3. Except major or mild neurocognitive disorder due to traumatic brain injury 4. Except major or mild neurocognitive disorder due to Prion Disease
3 Continued O. Personality disorders P. Paraphilic disorders Q. Other mental disorders R. Other conditions that may be a focus of clinical attention
4 ADULT PSYCHIATRIC HOSPITALIZATION CRITERIA Medical necessity of psychiatric inpatient admission must be documented based on conditions defined under either Section I or Section II. I. Criteria for Admission Based on Severity of Illness. A. Patient makes direct threats or a reasonable inference of serious harm to self or to the body or property of others. B. Violent, unpredictable or uncontrolled behavior, including patients with organic brain impairment and/or functional illness. C. Lack of insight, unwillingness or inability to adequately care for one s physical needs. Acute cases may include starvation or failure to take essential medications accurately and safely. D. Lack of response to previously attempted partial hospitalization management of medication and/or psychotherapy. II. Criteria for Admission Based on Intensity of Service. A. Need for daily skilled observation by both MD and RN staff (such as, but not limited to): 1. to confirm diagnosis; 2. to initiate medication regime; 3. to regulate dosage of potent medication; or 4. to withdraw potent medication. B. Need for electroconvulsive shock therapy. III. Criteria for Continued Stay. The treatment plan should include documentation of diagnosis, individualized goals of treatment and therapeutic modalities. The medical record must include daily progress notes by the psychiatrist or psychologist. While documentation may justify the need for continued hospitalization, the Medical Advisory Board expects that each service rendered by a physician or other provider of care and reported for payment be documented in the medical record. Documentation should include: A. the persistence of the problems that necessitated the admission, despite therapeutic efforts, or the emergence of additional problems consistent with the admission criteria. B. severe reaction to the medication or need for further monitoring and adjustment of dosage.
5 C. attempts at therapeutic re-entry into the community have resulted in exacerbation of the psychiatric illness. D. psychiatric evidence or rationale indicating the need for stabilization of patient s condition to a point where stress of community re-entry does not substantially risk an exacerbation of the psychiatric illness.
6 HOSPITALIZATION CRITERIA FOR SUBSTANCE DEPENDENCY (Applies to Psychiatric Hospitals and General Hospital Psychiatric Units) Admission to a psychiatric hospital is appropriate for alcohol and/or drug dependency of a severity which requires intensive intervention by a multi-disciplinary health care team including physicians, nurses, counselors, social workers, and other therapists. Evidence should be present that outpatient care or treatment in an intermediate care facility has been attempted recently, but has been unsuccessful. The patient also must have, in additional to substance dependency of a severity described above, a psychiatric disorder which inhibits his/her ability to be treated in a less intensive setting. There must be documented evidence of a present and acute psychiatric disorder of a severity which would require hospitalization in and of itself in accordance with the Adult Psychiatric criteria. I. SUBSTANCE DEPENDENCY CRITERIA FOR REHABILITATION SERVICES FOR ADMISSION Patient needs to meet the Adult Psychiatric Admission Criteria and both of the admission criteria given below. A. Patient has alcohol and/or drug dependency of a severity which requires intensive intervention, and at hospital level of care, by a multi-disciplinary health care team including physicians, nurses, counselors, social workers, and other therapists. Evidence that the patient cannot be treated in a residential center for substance abuse must be documented. B. Patient has, in addition to substance dependency of a severity described above, a psychiatric disorder which inhibits his/her ability to be treated in a less intensive setting. Evidence of a present and acute psychiatric disorder of a severity which would require hospitalization in accordance with the adult psychiatric criteria must be documented. II. CRITERIA FOR CONTINUED STAY The patient needs to meet the Adult Psychiatric Continued Stay Criteria, as well as (all of) A through D below. A. The treatment plan should include documentation for both the substance dependency and psychiatric disorders of individualized goals of treatment and therapeutic modalities. B. The medical record should include daily patient s progress notes by the psychiatrist, psychologist, or primary therapist. Evidence should be presented as to whether or not the problems necessitating admission have changed in response to specific treatment modalities being utilized.
7 C. Documentation of all therapeutic modalities being provided to the patient on a daily basis should be present and should specify the plan of treatment and patient s progress. D. Post-hospital treatment planning and referral efforts that have been conducted as soon as the initial evaluation is complete must be documented in the treatment plan and progress notes.
8 RESIDENTIAL TREATMENT CRITERIA FOR SUBSTANCE ABUSE I. CRITERIA FOR ADMISSION. Medical necessity for admission to a residential substance abuse treatment facility must be documented by the presence of all of the criteria below in Section A and Section B. In addition, it is noted that structured professional outpatient treatment is the treatment of first choice. Residential treatment, when indicated, should (a) be individualized and not consist of a standard, pre-established number of days, and (b) should follow recent outpatient treatment in a structured professional program of significant duration and intensity during the course of which the patient has not been able to maintain abstinence for a significant period of time. A. Severity of Need. 1. The provider must be able to document that the individual has a history of alcohol/substance dependence but is mentally competent and cognitively stable enough to benefit from admission to the inpatient program at this point in time. Individual days during any part of the stay where the patient does not meet this criterion cannot be certified as medically necessary. 2. Individual exhibits a pattern of severe alcohol and/or drug abuse as evidenced by continued inability to maintain abstinence despite recent professional outpatient intervention. If the patient has not been in a recent outpatient program (i.e., the past 3 months), then the following conditions must be met: 1) patient must be residing in a severely dysfunctional living environment; or 2) there must be actual evidence for, or clear and reasonable inference of serious imminent physical harm to self or others directly attributable to the continued abuse of substances which would prohibit treatment in an outpatient setting. 3. For individuals with a history of repeated relapses and a treatment history involving multiple treatment attempts, there must be documentation of the restorative potential for the proposed admission. B. Intensity of Service. Due to significant impairment in social, familial, scholastic or occupational functioning, the individual requires intensive individual, group, and family education and therapy in an inpatient rehabilitative setting. II. CRITERIA FOR CONTINUED STAY In addition to meeting all of the admission criteria on a daily, continued basis, there must be daily documentation supporting the need for continued inpatient treatment. All of A through C below need to be met. A. Progress Notes Daily documenting of the providers treatment, the patient s response to treatment, and the persistence of the problems that necessitated the admission,
9 despite treatment efforts, or the emergence of additional problems consistent with the admission criteria. B. The persistence of the problems that caused the admission to the degree that would necessitate continued inpatient care, despite therapeutic efforts, or the emergence of additional problems consistent with the admission criteria and to the degree that would necessitate continued inpatient care. C. Clear and reasonable evidence that re-entry into the community would result in exacerbation of the illness to the degree that would require an inpatient level of care.
10 CRITERIA FOR ADMISSION AND LENGTH OF STAY FOR ALCOHOL/DRUG DETOXIFICATION AND AN INPATIENT SETTING Patient must meet both of the criteria under the appropriate section. I. CRITERIA FOR ADMISSION A. Patient has a history of heavy and continuous alcohol/drug use requiring detoxification services where (a) there is the potential for serious physical harm from the side effects of withdrawal and (b) these services cannot be provided on an outpatient basis. Services that cannot be provided on an outpatient basis must require intensive nursing and medical treatment intervention on a 24-hour basis in order to be medically necessary on an inpatient basis. B. Patient presents signs and symptoms of impending withdrawal and/or history of seizures of delirium tremens and requires intensive nursing and medical treatment intervention on a 24-hour basis. II. CRITERIA FOR CONTINUED STAY A. Documentation of the need for skilled observation and medical treatment consistent with AEP criteria. B. Documentation of physical signs and symptoms of acute withdrawal which requires intensive nursing and medical treatment intervention on a 24-hour basis. This documentation must be noted three times daily, of which one such notation must be made by a physician.
11 Outpatient Treatment, Psychiatric and Substance Use Disorders, Rehabilitation Criteria for Treatment Status Review The specified requirements for severity of need and intensity and quality of service must be met to satisfy the criteria for the treatment review. I. SEVERITY OF NEED Criteria A, B, C, D and E must be met to satisfy the criteria for severity of need. A. The patient has a DSM-5 diagnosis. B. The presenting behavioral, psychological, and/or biological dysfunctions and functional impairment (occupational, academic, social) are consistent and associated with the DSM-5 psychiatric/substance-related disorder(s). C. One of the following: 1. The patient has symptomatic distress and demonstrates impaired functioning due to psychiatric symptoms and/or behavior in at least one of the three spheres of functioning (occupational, scholastic, or social), that are the direct result of a DSM-5 diagnosis. This is evidenced by specific clinical description of the symptom(s) and specific measurable behavioral impairment(s) in occupational, academic or social areas, or 2. The patient has a persistent illness described in DSM-5 with a history of repeated admissions to 24-hour treatment programs for which maintenance treatment is required to maintain community tenure, or 3. There is clinical evidence that a limited number of additional treatment sessions are required to support termination of therapy, although the patient no longer has at least mild symptomatic distress or impairment in functioning. The factors considered in making a determination about the continued medical necessity of treatment in this termination phase are the frequency and severity of previous relapse, level of current stressors, and other relevant clinical indicators. Additionally, the treatment plan should include clear goals needing to be achieved and methods to achieve them in order to support successful termination (such as increasing time between appointments, use of community resources, and supporting personal success). D. The patient does not require a higher level of care. E. The patient appears to be motivated and capable of developing skills to manage symptoms or make behavioral change. II. INTENSITY AND QUALITY OF SERVICE Criteria A, B, C, D, E, F, G, H, I, and J must be met to satisfy the criteria for intensity and quality of service. In addition, K must also be met for substance use disorders. A. There is documentation of a DSM-5 diagnosis. The assessment also includes the precipitating event/presenting issues, specific symptoms and functional impairments, community and natural resources, personal strengths, and the focus of treatment.
12 B. There is a medically necessary and appropriate treatment plan, or its update, specific to the patient s behavioral, psychological, and/or biological dysfunctions associated with the DSM-5 psychiatric/substance related disorder(s). The treatment plan is expected to be effective in reducing the patient s occupational, academic or social functional impairments and: 1. alleviating the patient s distress and/or dysfunction in a timely manner, or 2. achieving appropriate maintenance goals for a persistent illness, or 3. supporting termination. C. The treatment plan must identify all of the following: 1. treatment modality, treatment frequency and estimated duration; 2. specific interventions that address the patient s presenting symptoms and issues; 3. coordination of care with other health care services, e.g., PCP or other behavioral health practitioners; 4. the status of active involvement and/or ongoing contact with patient s family and/or support system, unless there is an identified, valid reason why such contact is not clinically appropriate or feasible; 5. the status of inclusion and coordination, whenever possible, with appropriate community resources; 6. consideration/referral/utilization of psychopharmalogical interventions for diagnoses that are known to be responsive to medication; 7. documentation of objective progress toward goals for occupational, academic or social functional impairments, target-specific behavioral, psychological, and/or biological dysfunctions associated with the DSM-5 psychiatric/substance-related disorder(s) being treated. Additionally, specific measurable interim treatment goals and specific measurable end of treatment goals, or specific measurable maintenance treatment goals (if this is maintenance treatment), are identified. Appropriate changes in the treatment plan are made to address any difficulties in making measurable progress; 8. the description of an alternative plan to be implemented if the patient does not make substantial progress toward the given goals in a specified period of time. Examples of an alternative plan are psychiatric evaluation if not yet obtained, a second opinion, or introduction of adjunctive or different therapies; and 9. the current or revised treatment plan can be reasonably expected to bring about significant improvement in the problems meeting Severity of Need Criteria (I above). This evolving clinical status is documented by written contact progress notes. D. The patient has the capability of developing skills to manage symptoms or make behavioral change and demonstrates motivation for change, as evidenced by attending treatment sessions, completing therapeutic tasks, and adhering to a medication regimen or other requirements of treatment. E. Patient is adhering to treatment recommendations, or non-adherence is addressed with the patient, and barriers are identified, interventions are modified, and/or treatment plan is revised as appropriate. F. Although the patient has not yet obtained the treatment goals, progress as relevant to presenting symptoms and functional impairment is clearly evident and is documented in objective terms. G. Treatment is effective as evidenced by improvement in GAF, SF-BH, CHI, and/or other valid outcome measures.
13 H. Requested services do not duplicate other provided services. I. Visits for this treatment modality are recommended to be no greater than one session per week, except for acute crisis stabilization (lasting no longer than four weeks). J. As the patient exhibits sustained improvement or stabilization of a persistent illness, frequency of visits should be decreased over time (e.g., once every two weeks or once per month) to reinforce and encourage self-efficacy, autonomy, and reliance on community and natural supports. K. For substance use disorders, treatment considers the use of medication-assisted treatment to address cravings and relapse prevention unless medically contra-indicated.
14 Psychological Testing Criteria for Authorization Prior to psychological testing, the individual must be assessed by a qualified behavioral health care provider. The diagnostic interview determines the need for and extent of the psychological testing. Testing may be completed at the onset of treatment to assist with necessary differential diagnosis issues and/or to help resolve specific treatment planning questions. It also may occur later in treatment if the individual s condition has not progressed since the institution of the initial treatment plan and there is no clear explanation for the lack of improvement. I. SEVERITY OF NEED Criteria A, B and C must be met: A. The reason for testing must be based on a specific referral question or questions from the treating provider and related directly to the psychiatric or psychological treatment of the individual. B. The specific referral question(s) cannot be answered adequately by means of clinical interview and/or behavioral observations. C. The testing results based on the referral question(s) must be reasonably anticipated to provide information that will effectively guide the course of appropriate treatment. II. INTENSITY AND QUALITY OF CARE Criteria A and B must be met: A. A licensed doctoral-level psychologist (Ph.D., Psy.D. or Ed.D.), medical psychologist (M.P.), or other qualified provider as permitted by applicable state law, administers the tests. B. Requested tests must be valid and reliable in order to answer the specific clinical question for the specific population under consideration. III. EXCLUSION CRITERIA Psychological testing will not be authorized under any of the following conditions: A. The testing is primarily for educational purposes. B. The testing is primarily for the purpose of determining if an individual is a candidate for a specific medication or dosage. C. The testing is primarily for the purpose of determining if an individual is a candidate for a medical or surgical procedure. D. The testing results could be invalid due to the influence of a substance, substance abuse, substance withdrawal, or any situation that would preclude valid psychological testing results from being obtained (e.g., an individual who is uncooperative or lacks the ability to comprehend the necessary directions for having psychological testing administered).
15 E. The testing is primarily for diagnosing attention-deficit hyperactive disorder (ADHD), unless the diagnostic interview, clinical observations, and results of appropriate behavioral rating scales are inconclusive. F. Two or more tests are requested that measure the same functional domain. G. Testing is primarily for forensic purposes, including custody evaluations, parenting assessments, for criminal charges or other court or government ordered or requested testing. H. Requested tests are experimental, antiquated, or not validated. I. The number of hours requested for the administration, scoring, interpretation and reporting exceeds the generally accepted standard for the specific testing instrument(s). PROTOCOL HISTORY: Passed: 9/01/1992 Amended: 11/19/2002 Amended: 6/12/2007 Amended: 12/17/2013
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